Kentucky has a culture and terrain that create a perfect storm for often deadly ATV accidents.
"Our state has a very rural community, and there is a big machine that is not being used as it is designed," said Dr. Joe Iocono, associate professor of surgery and pediatrics at the University of Kentucky.
Adding to the danger, those who ride routinely do so without protective gear, and most accidents happen far from medical care. People "just don't realize the risks," Iocono said.
And there are plenty.
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Kentucky leads the nation in ATV deaths, according to the Insurance Institute for Highway Safety. From 2007 through 2011, 122 people in Kentucky died riding ATVs. Pennsylvania ranked second with 97 deaths.
From January 2010 to July 2014, University of Kentucky Chandler Hospital treated 769 patients for trauma caused by ATVs. Of those, 163 were children. One child died. Of the 606 adults treated at UK, 23 died.
To help reduce those numbers, Carol Wright, a nurse and pediatric trauma care coordinator at UK, and Dr. Karen Lommel, an emergency room resident at UK, have been traveling around the state. They've surveyed hundreds of people about ATVs and safety, traveling to places like the Black Gold Festival in Hazard and World Chicken Festival in London.
They found that ATVs are so much a part of everyday life in many communities that the danger is overlooked.
About 80 percent of those surveyed had an ATV at home or one readily available. Many families use ATVs as a primary source of transportation, Lommel said. Use is so prevalent, it almost becomes part of the culture. Unfortunately, alcohol also is part of that culture, further increasing the risk of trauma, she said.
ATVs have no rear differential, which makes them prone to tipping on paved surfaces. "There are people who actually think it is safer to drive (ATVs) on the road," Wright said.
One of the most frustrating things for Lommel is that many accidents are preventable. If people wear helmets and boots, ride appropriately sized vehicles and stay off the roads, the number of people injured could be reduced dramatically. When they don't do those things, the results can be tragic.
ATV accidents usually cause trauma in two ways, Iocono said. Either the 2,000-pound machine lands on the head of a driver who is not wearing a helmet, or the driver is thrown from the ATV and slams his head into a tree or other solid object.
Iocono is especially disturbed by parents who let their children drive ATVs. He has seen children who have been garroted by wire fences while driving ATVs.
Lommel knows of some parents who rig the machines with wooden blocks so children can ride machines designed for adults, she said.
A "kid should not be on an ATV," he said, and he supported making ATV safety classes mandatory. "There is no other way to get around it. There is just no good reason."
Lommel and Wright continue to spread the message about the need for ATV safety. At a minimum, they would like to see people at least wear a helmet. They are especially trying to reach men ages 20 to 40 and mothers.
"It's very hard to change a culture," Lommel said.
Unfortunately, accidents can happen even when people follow the rules. Chuck Russell was working as a firefighter in April 2006 when he heard a call about an ATV accident in the Hazard Fire Department's coverage area. Within minutes, another station responded to the call.
Dispatchers, he said, knew that his brother, Rick, had been injured and didn't want to send him to the scene. Rick Russell died at the hospital.
Chuck Russell is sharing his story to let people know how dangerous ATVs can be. The brothers had ridden together since they were teens. And Rick Russell did everything he could to be safe. He was wearing a helmet. He was driving a vehicle he was familiar with in a place he knew well. He wasn't drinking alcohol.
"We had ridden up that hill 1,000 times," Chuck Russell said.
Even though he has helped care for many ATV riders in his job, losing his brother really brought the danger of the machines into view.
Chuck Russell had two heroes in his life: his brother and his father. "And when you have to look at the one and tell them the other is gone ... you never want to have to do that," he said.
"It wised me up," he said. "It made me stop and think. You never think it is going to happen to you."