Keeping the Wheels Turning
By Joey Berlin Texas Medicine October 2016

Hard Hats for Little Heads Events Promote Safety, Injury Prevention Among Children

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Public Health Feature — October 2016 

By Joey Berlin

Tex Med. 2016;112(10):33-37.

Any parent knows preaching to children about safety is a lot easier during the rapidly closing window of time when kids will actually listen. That's why Hard Hats for Little Heads, the Texas Medical Association's bicycle helmet safety program, aims to reach children before they enter high school, when they can become hardheaded headaches for aggravated parents.

"When you're 8, 9, 10 years old, you do what your parents say, but when you get to high school, your parents are so stupid. They don't know anything, and [they hear] 'Don't tell me [anything]. I don't need to wear a seat belt. I'm a careful driver,'" said Beaumont neurosurgeon Mark Kubala, MD, an active participant in Hard Hats since its 1994 inception.

At Hard Hats events, often combined with other community activities or health fairs, TMA members educate Texas children aged 3 to 14 on safety and give away free bike helmets. TMA has designated October as Hard Hats for Little Heads Month since 2014, holding a record 48 Hard Hats events in October that year. In 2009, TMA expanded the Hard Hats program to focus not only on head safety but also on the importance of staying physically active.

Dr. Kubala says when physicians engage in public health initiatives like Hard Hats, it highlights their benevolence. Physicians can get involved by hosting a giveaway, speaking about safety at a community or school event, or fitting helmets on children's heads at Hard Hats events.

The TMA Foundation funds Hard Hats for Little Heads this year with generous gifts from Blue Cross and Blue Shield of Texas, an anonymous physician and spouse couple, Make-A-Difference donors, the Baptist Health Foundation of San Antonio, individual physicians and their families, and other friends of medicine.

TMA organizations that sponsor Hard Hats events each year include the TMA Alliance and TMA's Medical Student Section chapters.

"I think it really connects the physicians and the alliance with the community," Dr. Kubala said. "When you are doing public health issues and the press comes in and publishes stories and pictures about the event, it's a win-win situation."

A Physician's Platform

The potential impact of a helmetless bike ride for a child is nothing short of catastrophic. Traumatic brain jury (TBI) contributes to about 30 percent of all injury deaths, according to the U.S. Centers for Disease Control and Prevention (CDC). TBI contributed to the deaths of more than 50,000 people in 2010, the most recent year CDC cites in its online fact page about TBI. Falls accounted for more than 40 percent of all U.S. cases of TBI that resulted in a visit to the emergency department, hospitalization, or death during 2006–10, making falls the leading cause. 

Falls caused 55 percent of TBIs among children aged 14 and younger during that 2006–10 period, and more than 100,000 children aged 5 to 14 paid a TBI-related visit to the emergency department because of a fall. 

In Texas, TBI results in more than 212,000 emergency department visits each year and 25,000 hospitalizations, according to a 2014 report by the Texas Traumatic Brain Injury Advisory Council. The state's Emergency Medical Services (EMS) Trauma Registry, which collected reports from approximately 50 percent to 60 percent of the state's hospitals in 2013, showed more than 3,000 TBI patients that year were children aged 14 and younger, according to the report. (See "TBI by the Numbers.")

The Hard Hats events in which Dr. Kubala participates highlight those dangers for kids in a stark but fun way.

"We take a small melon," Dr. Kubala says, "and say, 'This is your brain. Now what do you think will happen to it if we drop it?'"

After doing just that, and watching the melon crack and splinter, the presenters then put a helmet on a different melon and drop that one to demonstrate the protection the helmet provides.

A properly fitting helmet can reduce the risk of head injury by as much as 85 percent, according to the National Highway Traffic Safety Administration, and can reduce the risk of brain injury by as much as 88 percent. As a neurosurgeon, Dr. Kubala says an "ounce of prevention is worth a pound of cure."

"Probably no more so than in head trauma," he said, "because once you're injured in the brain, we can take out the blood clots; we can measure the pressure and control the brain edema. But often there's not much more we can do except support the brain in recovery, which unfortunately often is irreversible. Prevention is really the key."

Remote areas, such as West Texas, don't have specialists waiting around the corner if a child takes a severe tumble. Alpine family physician Adrian Billings, MD, began participating in Hard Hats about nine years ago and is a member of the Hard Hats for Little Heads Physician Advisory Panel. Dr. Billings says he got involved because he was mindful of how far Alpine is from a neurosurgeon who can provide care for head injuries.

The Alpine school board provides free bikes to all elementary school students with perfect attendance. Dr. Billings thought it might also be beneficial to provide a free helmet along with those bikes.

"If it's not the parents — and unfortunately many times the parent doesn't push the safety or doesn't see the value in it — then I think it's just really a nice platform that we as physicians can get on and say, 'We're a plane ride away from a neurosurgeon, you might die before you get there, and this is something that's really easy that can save your life,'" Dr. Billings said.

Hard Hats helps promote the importance of not just bike safety but also head protection in general. After all, a fall off a bike isn't the only way a child can suffer a head injury. Dr. Billings knows that too well; he rides horses with his three children, and each of them has either fallen off or has been thrown from their horses. His oldest son had such an incident about a year ago.

"He went over the dashboard of the horse, and on his helmet was dirt from where his head hit," Dr. Billings said. 

Luckily, his son was fine. But Dr. Billings says if it weren't for the helmet, his son may have ended up in the emergency department.

Benefits of Involvement

Any member of the TMA Family — individual physicians, medical students, county medical societies, and chapters of the TMA Alliance — can sponsor or host a Hard Hats giveaway. It might be a tiny gathering involving just a handful of helmets or a larger event at which dozens or hundreds of helmets are given away. 

In the 22 years since its founding by anesthesiologist Larry Driver, MD, the Hard Hats program has given away more than 235,000 helmets. Hard Hats has earned a number of honors from organizations that recognize outstanding public relations and public service programs, including the Texas Office for Prevention of Developmental Disabilities' J.C. Montgomery Jr. Child Safety Award in 2012.

Portland family physician James Mobley, MD, has been involved in Hard Hats events of widely varying sizes, from an event in Odem that gave away about a dozen helmets to a gathering with the Nueces County Medical Society that handed out about 800.

Dr. Mobley enlists the help of a group of teenagers from a medical careers club to deliver the safety lessons at his Hard Hats events. With that setup, he says there are four levels of benefit to the Hard Hats program:  

  1. The children in attendance may be more likely to listen to teens than to adults; 
  2. Teens pass on lessons about the importance of safety to their own friends; 
  3. The children "go home and teach their parents" about the importance of safety; and 
  4. The events promote safety and injury prevention awareness among physicians "because it's something that I don't always think about when I see my patients." 

He estimates that more than 80 percent of children who attend Hard Hats events need a helmet and probably wouldn't be able to obtain one otherwise.

"We're definitely hitting a group that it's not a second helmet for them; it's the only helmet," he said.

The helmets for an event cost $7.60 each, including shipping. TMA provides a one-to-one match on purchases of up to 50 helmets. For a purchase of more than 50, TMA matches on a sliding scale. For more information, see these Hard Hats FAQs.

The Texas Pediatric Society (TPS) and the Texas Academy of Family Physicians (TAFP) offer their members assistance for hosting helmet giveaways. TPS and TAFP will cover the cost of up to 25 helmets for members who host a giveaway. TMA will provide an equal match of 25 helmets, giving TPS and TAFP members the ability to give away up to 50 helmets at no cost.

Tailored to the Community

Dr. Kubala says one of the great things about the Hard Hats program is its flexibility. Participating physicians and organizations can find a venue and format that works locally. Examples of past events include combining Hard Hats events with health fairs, fitness events, and immunization events, such as a TMA's Be Wise — ImmunizeSM shot clinic. Be Wise – Immunize is a joint initiative led by TMA physicians, medical students and the TMA Alliance. It is funded by the TMA Foundation thanks to major gifts from H-E-B and TMF Health Quality Institute, along with generous contributions from physicians and their families.

Local community and civic groups, police and EMS departments, schools, and other organizations, such as Pilot Club International, which focuses on brain-related disorders, often collaborate with TMA sponsors on the Hard Hats program. The events Dr. Kubala spearheads are in conjunction with the TMA Alliance and the Jefferson County Medical Society.

"In each community, the needs are different, and it's dependent upon the community as to how the bicycle helmets are given out, whether they're in conjunction with some other health program or whether they're just a separate freestanding program," Dr. Kubala said. "It's a program that easily fits into your type of situation."

Physicians who want to participate in or sponsor a Hard Hats for Little Heads event can call (512) 370-1470 or email TMA's outreach coordinator. For more information on the program, including an event toolkit, FAQs, and other links, visit the program website

Like Dr. Mobley, Dr. Kubala has seen the impact Hard Hats can have when young children absorb the safety lessons and not only protect themselves but also challenge loved ones to do the same.

"It's interesting," he said. "One of the things we've found is that by having the children wear their helmets so frequently, the child will say, 'Well Daddy, when you go riding, you don't have a helmet. If the helmet is good for me, why isn't it good for you?'"

Be Wise ― Immunize is a service mark of the Texas Medical Association.

Joey Berlin can be reached by phone at (800) 880-1300, ext. 1393, or (512) 370-1393; by fax at (512) 370-1629; or by email.


TBI by the Numbers

Traumatic brain injury (TBI) patients aged 14 and younger recorded in Texas' EMS Trauma Registry in 2013

Annual TBI hospitalizations per year in Texas

U.S. TBI-related emergency department visits among children aged 0 to 4 per 100,000 population during 2009–10

Source: Texas Traumatic Brain Injury Council, Recommendations for Improving the Lives of Individuals With Traumatic Brain Injury, 2014; U.S. Centers for Disease Control and Prevention

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Get Involved in Hard Hats

To find out more about participating in or sponsoring a Hard Hats for Little Heads event, call (800) 880-1300, ext. 1470, or (512) 370-1470, or email TMA's outreach coordinator

To make a tax-deductible donation to the Hard Hats program, visit the TMA Foundation website, For more information on the programs the foundation funds, contact Lisa Stark Walsh at (800) 880-1300, ext. 1666, or (512) 370-1666.


Last Updated On

April 23, 2018

Originally Published On

September 14, 2016

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Hard Hats for Little Heads

Joey Berlin

Associate Editor

(512) 370-1393

Joey Berlin is associate editor of Texas Medicine. His previous work includes stints as a reporter and editor for various newspapers and publishing companies, and he’s covered everything from hard news to sports to workers’ compensation. Joey grew up in the Kansas City area and attended the University of Kansas. He lives in Austin.

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