Whether making snow angels, ice skating, or eating a whole roll of chocolate chip cookie dough, Christmas involves a plethora of traditions and activities for families. Many enjoy watching classic films during the holiday season, and Christmas movies can vary widely, from the sensational, heroic feats of an underdog police officer trying to reunite with his wife (“Die Hard”) to the valiant efforts of a young boy defending his home (“Home Alone”) and the incorrigible antics of fathers attempting to create the perfect Christmas (“National Lampoon's Christmas Vacation”).
The one thing many of these films share, however, is a common theme: unintentional injury. These injuries are a known consequence of the holiday season. (Clin Pediatr [Phila]. 2019;58[5]:571; Pediatrics 2010;125[5]:931.) Ingestion of Christmas ornaments, burns from Christmas tree fires, and falls over decorations are common depicted. There has also been great debate over which Christmas movie is the most realistic, that is, which most accurately represents real life injuries. We think cinematic art imitates life and that the injuries depicted in Christmas films do indeed occur during the holiday season.
We investigated the epidemiology of Christmas movie-related injuries among adults treated in U.S. emergency departments from 2017 to 2021, hypothesizing that we could identify which Christmas movie is the most realistic from an injury perspective.
Ten Classic Films
We compared injury scenes in top-rated Christmas films with actual injury encounters catalogued in the National Electronic Injury Surveillance System (NEISS). This database records ED visits for injuries related to consumer products nationwide. Because all encounters catalogued in NEISS must be related to injury from a consumer product, the database can be used as a surrogate for overall ED injury trends only (i.e., NEISS does not provide incidence data on disease such as viral upper respiratory infections). The system functions as a stratified national probability sample of hospitals that provide 24-hour emergency medical services, have at least six beds, and contain an ED.
We first reviewed lists of the top Christmas films separately curated by IMDB and Rotten Tomatoes with an emphasis on comedies. Films that occurred on both lists were included and a final list of 10 films was included for investigation including: “A Christmas Story,” “Daddy's Home 2,” “Deck the Halls,” “How the Grinch Stole Christmas,” “Elf,” “Home Alone,” “National Lampoon's Christmas Vacation,” “The Santa Clause,” “Jingle All the Way,” and “Die Hard.” (IMDb. Dec. 16, 2014; http://bit.ly/3gLVqqv; Rotten Tomatoes. http://bit.ly/3Uiy4X9.) There is some controversy about whether “Die Hard” is a Christmas movie, but we agreed with the criteria described by the Hollywood Reporter: A Christmas movie must occur during the Christmas season, and Christmas is meaningfully used in the movie's storytelling. (The Hollywood Reporter. Dec. 23, 2018; http://bit.ly/3UmuXxo.) “Die Hard” qualifies given its comedic, juxtaposed dispositions of the protagonist and antagonist (rest in peace).
We reviewed each film to catalogue injury patterns depicted in the story including culprit objects (e.g., pellet gun) and a potential diagnosis (e.g., ocular injury). Eighty scenarios were generated from the 10 Christmas films. These scenarios were then compared and matched to the available product and diagnostic codes in the 2021 NEISS coding manual. (National Electronic Injury Surveillance System. http://bit.ly/3XOMlhA.)
We used the NEISS data to evaluate the incidence of Christmas movie-related injuries in adults who presented to EDs from Jan. 1, 2017, through Dec. 31, 2021, with encounters that fit the criteria for one of our 80 scenarios. We included cases from Nov. 1 of each year (start of the Christmas season) to January 31 (end of the Christmas season). A single Christmas year celebratory season (celebratory season) included temporally linked days from November to January of follow-on years (i.e., the days in December 2020 leading up to Christmas and the period following New Year's Day on Jan. 1, 2021, were reported as Christmas year group 2020).
This was performed to capture Christmas movie-related injuries associated with setting up and taking down Christmas décor. We eliminated cases outside of this range. Escalation of care was assigned to cases that were treated and transferred, treated and admitted or hospitalized, or held for observation. A total of 188,822 cases were excluded, leaving 53,195 of the 242,017 cases originally obtained from NEISS for the to be examined.
The NEISS provided weights that were applied in all analyses to generate national estimates with 95% confidence intervals. The Rao-Scott Chi-square test was used for all categorical comparisons, and SAS 9.4 (SAS Institute, Cary, NC) was used for all analyses. This study was approved by the Walter Reed National Military Medical Center Institutional Review Board.
No ‘Die Hard’ Injuries
An estimated 2,315,633 (CI 1,976,358-2,654,909) Christmas movie-related injuries occurred from 2017 to 2021 that matched one of the Christmas movie scenarios generated from 53,195 actual ED encounters (Table 1). Almost 68 percent of the injured subjects were age over 40 (median age 53.9, interquartile range (IQR) 32.2-71.7). Fifty-five percent of subjects were female (estimated n=1,275,908, CI 1,085,998-1,465,818).
Table 1. -
U.S. ED Visits for Injuries Matching Christmas Film Scenes, 2017-2021
|
Total Christmas Movie-related Injuries
|
Actual no. (%)
|
Estimated no. (95% CI)
|
| 53,195 (100) |
2,315,633 (1,976,358-2,654,909) |
|
Age
|
| 18-24 |
5371 (10.1) |
226,026 (193,667-258,385) |
| 25-39 |
11,954 (22.5) |
506,583 (435,272-577,894) |
| 40-64 |
20,017 (37.6) |
869,368 (746,145-992,592) |
| ≥65 |
15,853 (29.8) |
713,656 (572,343-854,970) |
|
Sex
|
| Female |
29,066 (54.6) |
1,275,908 (1,085,998-1,465,818) |
| Male |
24,129 (45.4) |
1,039,725 (855,691-1,193,760) |
|
Disposition
|
| Released |
45,061 (84.7) |
1,979,797 (1,692,338-2,267,257) |
| Escalation of care |
8134 (15.3) |
335,836 (266,138-405,534) |
The majority of these injuries occurred within the home (55.3%) or in a location that did not have a code defined by NEISS (i.e., unknown, 37.7%). Fifteen percent (estimated n=335,836, CI 266,138-405,534) of subjects required escalation of care.
The cohort was stratified by the 10 films selected for investigation, and “National Lampoon's Christmas Vacation” recorded 52.4 percent of Christmas movie-related injuries (estimated n=2,016,557, CI 1,723,188-2,309,926) (Figure 1 and Table 2.) “Home Alone” demonstrated the second most frequent Christmas movie-related injuries (32.5%) with an estimated 1,238,586 ED visits (CI 1,046,959-1,430,213). A total of 57.9 percent of Christmas movie-related injuries assigned to “National Lampoon's Christmas Vacation” (estimated n=309,684, CI 245,678-373,690) required escalation of care. The movie with the second highest rate of care escalation was “Home Alone” (36.1% escalation of care, estimated n=188,946, CI 144,290-233,602). “Die Hard” scenarios recorded no ED encounters during the study timeline.
Table 2. -
Rates of Christmas Film Injuries and Rates of Escalation of Care, 2017-2021
|
Christmas Film-related Injuries |
Escalation of Care |
| Movie |
Actual No. (%) |
Estimated No. (95% CI) |
Actual No. (%) |
Estimated No. (95% CI) |
| National Lampoon's Christmas Vacation |
46,731 (52.4) |
2,016,557 (1,723,188-2,309,926) |
7524 (57.9) |
309,684 (245,678-373,690) |
| Home Alone |
29,024 (32.5) |
1,238,586 (1,046,959-1,430,213) |
4687 (36.1) |
188,946 (144,290-233,602) |
| Elf |
8343 (9.4) |
370,762 (313,785-427,738) |
123 (1.0) |
5120 (3839-6401) |
| Jingle All the Way |
2968 (3.3) |
136,796 (112,151-161,441) |
302 (2.3) |
13,483 (9376-17,590) |
| Deck the Halls |
873 (0.9) |
38,728 (30,630-46,827) |
159 (1.2) |
6686 (4953-8418) |
| The Santa Clause |
702 (0.8) |
30,566 (24,060-37,072) |
128 (1.0) |
5148 (3810-6487) |
| Daddy's Home 2 |
326 (0.4) |
16,892 (11,617-22,167) |
41 (0.3) |
1868 (1063-2672) |
| A Christmas Story |
202 (0.2) |
9173 (7416-10,930) |
26 (0.2) |
- |
| How the Grinch Stole Christmas |
54 (0.1) |
2474 (1485-3463) |
4 (<0.1) |
- |
| Die Hard |
0 |
0 |
0 |
0 |
;)
Figure 1.: National Incidence Rates for Christmas Film-related Injuries that Match Christmas Film Scenes in the United States, 2017-2021
|
Christmas Movie-related Injuries
|
Actual No. (%)
|
Estimated No. (95% CI)
|
| 53,195 (100) |
2,315,633 (1,976,358-2,654,909) |
|
Age
|
| 0-24 |
5371 (10.1) |
226,026 (193,667-258,385) |
| 25-39 |
11,954 (22.5) |
506,583 (435,272-577,894) |
| 40-64 |
20,017 (37.6) |
869,368 (746,145-992,592) |
| 65+ |
15,853 (29.8) |
713,656 (572,343-854,970) |
|
Sex
|
| Female |
29,066 (54.6) |
1,275,908 (1,085,998-1,465,818) |
| Male |
24,129 (45.4) |
1,039,725 (855,691-1,193,760) |
|
Diagnosis
|
| Soft tissue injury |
174,139 (68.4) |
7,723,324 (6,404,311-9,042,337) |
| Fracture |
41,014 (16.1) |
1,819,984 (1,466,701-2,173,267) |
| Sprain |
32,147 (12.6) |
1,405,837 (1,116,773-1,694,902) |
| Poisoning |
2739 (1.1) |
117,862 (96,506-139,219) |
| Burn |
2035 (0.8) |
80,036 (65,034-95,038) |
| Rash |
1494 (0.6) |
68,191 (50,852-85,531) |
| Amputation |
492 (0.2) |
18,907 (14,920-22,894) |
| Foreign body ingestion |
444 (0.2) |
18,691 (14,260-23,122) |
| Frostbite |
113 (0.0) |
4036 (2455-5617) |
Rx: Watch Movies
This is the first time popular Christmas films have been analyzed to determine which cinematic feature is most realistic from an injury perspective. The results confirmed that several Christmas films, specifically “National Lampoon's Christmas Vacation” and “Home Alone,” contained the most common, ergo most realistic, injury scenes. These two films also exhibited the highest rates of care escalation required for Christmas movie-related injuries. Given the popularity of these films, these findings may present an opportunity for patient education and injury prevention for future holiday seasons.
John Mundy in the book Christmas, Ideology and Popular Culture described Christmas in the United States as a frame of mind, the construction of which relies on visual imagery, specifically films. (Edinburgh University Press. 2008; http://bit.ly/3XLpwuX.) Christmas films are an ever-present, growing phenomenon in popular culture, and using them as medical education for medical staff and patients is not new. Two articles also described using films to enhance knowledge transfer for addiction medicine and infectious disease outbreaks, respectively. (Adv Med Educ Pract. 2021;12:265; http://bit.ly/3Vd6a09; Int Rev Psychiatry 2009;21[3]:213.)
Given the evidence, we propose that primary care providers recommend that age-appropriate patients watch “National Lampoon's Christmas Vacation” prior to each holiday season. This practice could provide enjoyment, wellness, and a pre-injury intervention to update patients on the risks of the holiday season. Appropriate preparedness could potentially decrease injury rates and subsequently improve the holiday season for patients.
| Movie |
Scenario |
NEISS Product (NEISS Activity Code) |
| A Christmas Story |
Heat stroke/heat exhaustion from winter clothing (“too bundled up”) |
Outerwear (1646); other clothing (1677); clothing accessories (1647) |
|
Head injury from BB gun |
BB guns (1237); BBs or pellets (1936) |
| Daddy's Home 2 |
Amputation or laceration from snow blower; injury from shoveling snow or using snow blower |
Snow throwers or blowers (1406) |
|
Fall or injury from sledding; head injury from sledding, tubing, discs, or toboggans |
Sleds (1217); snow tubes (1299); snow disks (1274); toboggans (1273) |
| Deck the Halls |
Burns from fireworks |
Fireworks (1313) |
|
Burns from hot glue guns used in ornament construction |
Glue gun (0869) |
|
Electrocution/electric shock from Christmas lights |
Christmas lights, electric (1736) |
|
Electrocution/electric shock from Christmas tree lights |
Christmas tree lights (1711) |
|
Electrocution/electric shock from circuit breakers/panel boards |
Electrical wire or wiring systems (4062) |
|
Electrocution/electric shock from outlet |
Electrical outlets or receptacles (4061) |
|
Fall or injury from tripping over extension cord |
Electric extension cords (0685); cords electrical other or not specified (4081) |
|
Strain/sprain from cutting down Christmas tree |
Hand saws (unpowered) (0830); hatches or axes (1426) |
|
Fall or injury from ladder when hanging or taking down Christmas decorations |
Extension or straight ladders (4077); step ladders (0618) |
| How the Grinch Stole Christmas |
Burns from hot glue guns used in homemade ornaments construction |
Glue gun (0869) |
|
Dental injury from biting Christmas tree lights; ingestion of Christmas tree lights |
Christmas tree lights (1711); artificial Christmas tree (1701) |
|
Dental injury from biting glass or non-glass Christmas ornament; ingestion of Christmas decorations, non-electric |
Christmas decorations, non-electric (1729) |
|
Oral laceration/dental injury from hors d'oeuvre toothpicks; ingestion of hors d'oeuvre toothpicks |
Hors d'oeuvre picks (0431) |
|
Ingestion of artificial Christmas trees |
Artificial Christmas tree (1701) |
|
Ingestion of artificial Christmas flowers and plants |
Artificial flowers or plants (0653) |
| Elf |
Ingestion of Christmas decorations, electric |
Christmas decorations, electric (1736) |
|
Ingestion of cotton balls |
Manicure, pedicure, and make-up brushes and tools (excluding cosmetics) (1659) |
| Elf |
Ingestion of holiday-inspired aromatherapy/essential oil/perfume |
Cosmetics (1913) |
|
Crushing injury from falling Christmas tree |
Artificial Christmas tree (1701) |
|
Laceration from opening/wrapping gifts with a knife or scissors |
Knives not elsewhere classified (0464); knives with replaceable blades (0836); manual scissors (0420); electric scissors (0232) |
|
Laceration and additional injuries from cardboard and paper Christmas decorations |
Cardboard products (1114); paper products (1137); Christmas decorations non-electric (1729) |
| Home Alone |
Laceration from broken Christmas ornaments; embedded foreign body from stepping on ornaments, decorations, and tree lights; foot puncture from stepping on Christmas ornaments, decorations, and tree lights |
Christmas decorations, non-electric (1729); Christmas tree lights (1711) |
|
Burns from candles |
Candles, candlesticks, and other candle holders (0463) |
|
Puncture from BB gun; head injury from BB gun |
BB gun (1237); BBs or pellets (1936) |
|
Burn from heated doorknob |
Cabinet or door hardware (1820) |
|
Head injury from snow shovel |
Manual snow or ice removal tools (1415) |
|
Fall from slipping on toy vehicles, stacking blocks, or balls |
Toy vehicles (5021); blocks/stacking toys (1326); balls other or not specified (5016) |
|
Foot puncture from a nail in stairs |
Nails, screws, tacks, or bolts (1819) |
|
Burn/head injury/fracture to the face from swinging iron |
Clothing iron (0277) |
|
Head injury and dental injury from paint bucket or pail |
Bucket or pail (1143) |
|
Fall from rope zip line/playground equipment |
Rope or string (0852); other playground equipment (3219) |
|
Fall down the stairs |
Stairs or steps (1842) |
| National Lampoon's Christmas Vacation |
Electrocution/electric shock from power strips |
Surge suppressors or power strips (4083) |
|
Fall down the stairs |
Stairs or steps (1842) |
|
Fall from attic ladder/pull down or folding stairs when gathering or returning Christmas decorations; head injury from attic ladders (pull down) |
Attic ladders (4078); pull down or folding stairs (1840) |
| National Lampoon's Christmas Vacation |
Fall or injury from step stools/stools |
Step stools (0620); barstools (4025); footstools (4079); stools not specified (4080); chairs (4074) |
|
Frostbite/hypothermia from cutting down Christmas tree; strain/sprain from cutting down a Christmas tree |
Hand saws (unpowered) (0830); hatches or axes (1426) |
|
Frostbite/hypothermia from sledding; head injury from sledding/snow tubing/snow discs/toboggans |
Sleds (1217); snow tubes (1299); snow disks (1274); toboggans (1273) |
|
Head injury from falling Christmas tree; ocular injury from Christmas tree |
Artificial Christmas tree (1701) |
|
Laceration from carving turkey or ham |
Carving knives electric/battery powered (0218); knives not elsewhere classified (0464) |
|
Fall or injury from sledding |
Sleds (1217); snow tubes (1299); snow disks (1274); toboggans (1273) |
|
Electrocution/electric shock from Christmas lights |
Christmas lights, electric (1736) |
|
Electrocution/electric shock from Christmas tree lights |
Christmas tree lights (1711) |
|
Electrocution/electric shock from circuit breakers/panel boards |
Electrical wire or wiring systems (4062) |
|
Electrocution/electric shock from outlet |
Electrical outlets or receptacles (4061) |
|
Fall or injury from tripping over extension cord |
Electric extension cords (0685); cords electrical other or not specified (4081) |
|
Fall or injury from ladder when hanging or taking down Christmas decorations |
Extension or straight ladders (4077); step ladders (0618) |
|
Puncture from heavy duty staple gun |
Heavy-duty staple gun (0834) |
| The Santa Clause |
Burns from aluminum foil roasting pans |
Aluminum foil roasting pans (0465) |
|
Burns from baking pans |
Metal cookware (0460); nonmetal cookware (0461); cookware (0466) |
|
Burns from fireplace |
Fireplaces built-in (0336); electric (0346); gas (0334); wood burning (0316); not specified (0342) |
|
Fall or injury from ladder when hanging or taking down Christmas decorations |
Extension or straight ladders (4077); step ladders (0618) |
| Jingle All the Way |
Fall from climbing on store shelves for a toy |
Cabinets, racks, room dividers, and shelves, not elsewhere classified (4056) |
|
Laceration, contusion, abrasion from falling into toy carboard boxes |
Cardboard products (1114); toy boxes or chests (1353) |
| Jingle All the Way |
Fall from slipping on remote control toy vehicle |
Toy vehicles (5021) |
|
Ocular injury and chemical burn to the face from pepper spray; electric shock and burn from being tasered |
Personal protective devices (1619) |
|
Head and body injury from being hit with handbags/purses |
Clothing accessories (1647) |
|
Body injury after being hit with giant plastic decoration candy cane; thermal burn from non-electric Christmas decorations catching on fire |
Christmas decorations, non-electric (1729) |
|
Head injury from being hit on the head by a telephone |
Telephone and telephone accessories (0550) |
|
Thermal burn from fireworks |
Fireworks (1313) |
|
Head injury from toy weapon with disc-like projectiles |
Toy gun with projectiles (1399); other toy weapons projectile (5001) |
|
Christmas Movie-related Injuries |
Escalation of Care |
| Movie |
Actual No. (%) |
Estimated No. (95% CI) |
Actual No. (%) |
Estimated No. (95% CI) |
| National Lampoon's Christmas Vacation |
46,731 (52.4) |
2,016,557 (1,723,188-2,309,926) |
7524 (57.9) |
309,684 (245,678-373,690) |
| Home Alone |
29,024 (32.5) |
1,238,586 (1,046,959-1,430,213) |
4687 (36.1) |
188,946 (144,290-233,602) |
| Elf |
8343 (9.4) |
370,762 (313,785-427,738) |
123 (1.0) |
5120 (3,839-6,401) |
| Jingle All the Way |
2968 (3.3) |
136,796 (112,151-161,441) |
302 (2.3) |
13,483 (9376-17,590) |
| Deck the Halls |
873 (0.9) |
38,728 (30,630-46,827) |
159 (1.2) |
6686 (4953-8418) |
| The Santa Clause |
702 (0.8) |
30,566 (24,060-37,072) |
128 (1.0) |
5148 (3810-6487) |
| Daddy's Home 2 |
326 (0.4) |
16,892 (11,617-22,167) |
41 (0.3) |
1868 (1063-2672) |
| A Christmas Story |
202 (0.2) |
9173 (7416-10,930) |
26 (0.2) |
1311 (698-1924 |
| How the Grinch Stole Christmas |
54 (0.1) |
2474 (1485-3463) |
4 (<0.1) |
191 (0-418) |
| Die Hard |
0 |
0 |
0 |
0 |
Our study had limitations. The NEISS contains data from EDs only, possibly resulting in an underestimation of the number and rates of Christmas-related injuries because some cases may have been managed at home or in urgent care or primary care settings. Despite these limitations, this study's strengths stem from its use in a large, nationally representative dataset and a large timeframe.
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