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The irony for Meghan Glaser was that she was already checking for a bicyclist–the one to her right, stationary at a stop sign in the coastal La Jolla neighborhood near San Diego. She never saw the two cyclists on her left, high-school students who’d blown through their own stop and were trying to beat her car through the intersection. The cyclist in front cleared her; the second clipped her front bumper with his rear tire and went flying.
It was just a road rash, thankfully, mostly knees and elbows. The student popped up immediately and appeared otherwise fine, and he was wearing a helmet. But when Glaser later looked at dashboard video from a car that happened to be nearby when the incident occurred, she was deeply shaken.
“Honestly, I was going fast enough and they were going fast enough that it could have been fatal,” she told me. “I never saw them because they were going so fast.”
The boys were blasting through the intersection at a speed neither of them likely would ever reach on a conventional bicycle. But because the lead cyclist was on an electric bike, with the trailing cyclist hanging on to it with one hand and steering his bike with the other, Meghan Glaser’s recollection wasn’t faulty: The boys really were going fast enough that something far worse could have occurred.
Increasingly, some trauma specialists say that is precisely what they’re seeing. Though the record-keeping on severe e-bike injuries is spotty, both anecdotal evidence and emergency, trauma and orthopedic department interviews suggest that we’re on the front edge of a new order of danger on both bike paths and roadways.
“I honestly believe that we probably are only seeing the tip of the iceberg,” says Dr. Marko Bukur, medical director of trauma at New York’s Bellevue Hospital and himself an avid cyclist. “A lot of the injuries that are coded (in the electronic medical record) as conventional powered devices are probably e-devices.”
The bigger problem: We have no coherent plan for dealing with it.
While reliable numbers are elusive, the pattern isn’t. According to the U.S. Consumer Product Safety Commission (CPSC), emergency visits due to micromobility-related accidents (e-bikes, e-scooters, and hoverboards) more than doubled from 2017 to 2021. The National Transportation Safety Board (NTSB), meanwhile, counted 53 deaths from e-bike accidents from that same period and it decried the “lack of complete, consistent and reliable data” that likely leads to vast underestimations of the actual statistics. The NTSB report cited a UCLA study of data collected from 180 outpatient clinics which concluded that e-bikes may lead to higher fatality rates than either motorcycles or cars. And a Dutch study found that e-bike riders were 1.6 times more likely to wind up in the emergency department than riders of regular bikes.
Those statistics will likely continue to balloon. E-bike sales are taking off, as people increasingly flock to the idea of a bicycle that can be pedaled, but with the motor doing the work when wanted or needed. E-bikes can take riders from 20 mph to nearly 30 mph, or faster than the average Tour de France rider-the kind of top speeds an average cyclist would never attain on their own.
In the U.S. alone, almost 900,000 e-bikes were sold in 2021, a near doubling of sales from just one year earlier. According to a report by the National Bicycle Dealers Association, total sales revenues surpassed $1.3 billion in 2022, a 33% increase from the previous year.
“It’s opened up the world to a wide range of individuals,” says Tracy Sheffer, co-owner of the e-bike retailer Pedego’s store in La Jolla. “Kids that used to sit in the house and play video games all day are now on electric bikes and they’re getting out and getting active.”
Industry analysis suggests that a surge of interest from baby boomers is also driving demand. But for teens and retirees alike, these top speeds are no joke. They are residential-street auto speeds, essentially, and trauma specialists say it’s more than enough locomotion to produce severe injury. Yet in the U.S., there’s a near-total absence of cohesive policies or regulations to deal with that reality. This is a product that, governmentally at least, doesn’t fall neatly into any single category.
“The vehicle is heavier. I consider it a vehicle,” says Dr. Joseph Patterson, an orthopedic trauma surgeon at USC’s Keck Medical Center in Los Angeles. (Generally, e-bikes weigh between 50-80 pounds.) “The patients are ejected at higher speed, but unlike most motorcycles, they’re not wearing protective equipment. There’s no helmet law for them.”
This is partly because e-bikes in many states are placed in the same category as conventional bicycles, and riders are thus required to wear only a bike helmet-and even then only within certain age ranges in many states. Other states have outdated laws that don’t include a classification for e-bikes at all. The CPSC, meanwhile, regulates them as traditional, human-powered bikes, and the federal government explicitly excludes them from any motor vehicle category.
That leaves much of the regulatory responsibility to local governing bodies, with a resulting crazy quilt of rules. In some cities or states, e-bikes have access to bike paths and bike lanes; in others, they ride the road in front of and behind full-size cars. In most states, they are exempt from registration or licensing requirements.
But people in e-bike accidents don’t look like people in conventional bicycle mishaps, according to trauma surgeons in larger metro areas where e-bikes are becoming legion. “Patients have fractures that are more likely to be open, where the bones come out of the skin,” says Patterson. “We’re seeing a higher instance of polytrauma, meaning more than one part of their body or more than one organ system is seriously injured. We’re seeing more serious injuries overall, patients needing to come into the hospital for longer and needing more surgeries.
To Patterson, who says the incidence of such e-bike accidents “is clearly going up,” the severity of these injuries resemble those from motorcycle crashes more than standard bike collisions or falls. And Dr. Charles DiMaggio, director of injury research at NYU’s Langone Department of Surgery and author of a widely circulated analysis of data from 2000-2017, says e-bikes “were three times more likely to result in hospitalization when compared to traditional pedal cycles, with many e-bike related hospital discharges coded as internal injuries.”
“We are really seeing the gamut,” Bellevue’s Bukur told me. “This includes head and neck injuries, traumatic brain injury, spine fractures, chest injuries, solid organ injuries and extremity fractures, of course. We have had a plethora of people that have been on e-powered devices and definitely getting banged up really bad. I mean, ICU level of care.”
To these specialists, the risks are obvious. Older riders may have slower reaction times, are more prone to serious injury–and don’t bounce back as quickly from accidents. Younger riders have likely never been on anything as fast as an e-bike and have limited decision-making skills in quick-changing settings, as Meghan Glaser discovered in La Jolla, but they are industrious: There are already plenty of videos explaining how to hack e-bike motors to go much faster than 30 mph.
Add in risky and dangerous behaviors such as drunk biking, “retrograde cycling”, ignoring traffic lights and using cell phones while e-cycling, and you have a recipe for disaster. A Chinese study found that these behaviors were higher in those with e-bike-related traffic injuries than in those without such injuries.
“I’ve seen kids younger than teenagers riding them. I’m not happy when I see that,” says Dr. Gabe Wardi, a practicing emergency and critical care physician at University of California San Diego Health. “This is a motorized vehicle that goes on the road (with cars), which is not ideal for someone who’s 12 or 13, but these kids also take full advantage of the fact that you can cut through neighborhoods on paths where you’re supposed to either walk or be on a non-motorized bicycle. They probably don’t know the rules of the road.”
Should they? As e-bikes continue to grab market share in the U.S., it is a question worth asking. The industry trade group PeopleForBikes wants the three common classes of e-bikes regulated strictly as bicycles. But the rising incidence of severe injury calls for a close examination of other options.
There is a public safety interest, too. In DiMaggio’s study, e-bike accidents were three times more likely to involve a collision with a pedestrian than either traditional bikes or powered scooters. (Again, think speed.) And because U.S. infrastructure lags so far behind developments like this, there aren’t enough dedicated bike lanes in major cities-a common theme that, of course, predates the e-bike movement by decades.
“You have to put the infrastructure there for people to use it,” says Elizabeth Bowersox, program director of the San Diego Bike Coalition. “The city has to take that initiative first and put that infrastructure there, and then people will use it.”
That’s one area in which to work, but it requires a long view. In the meantime, trauma specialists say, enforcing strict helmet laws is practically a must, and figuring out either licensing/certification requirements or mandatory education-especially for renters-is something to strongly consider.
“There needs to be a classification for something between a motor vehicle and motorcycle and a regular bicycle,” says USC’s Patterson. “And I know California law; it’s based on wattage and maximum speed. But, I’m not sure if that’s protecting people…I’m seeing them come in at speeds of 30 to 40-plus, sometimes 50 miles an hour.”
This may feel like a major-metro issue, but it won’t be long before communities across the country are dealing with the ramifications of the e-bike explosion. It’s the fastest-growing segment of the bike industry in terms of sales, and the proliferation of bikes capable of traveling at car speeds cannot be safely ignored.
“The helmet is definitely warranted, and I think there’s probably going to have to be an age restriction or a minimum age on at least some of them,” says Dr. Linda Dultz, a trauma surgeon in Dallas. “I can’t imagine a 13-year-old being able to drive something that can go 25 to 30 miles an hour in the middle of a road. It just doesn’t seem safe.”
Carolyn Barber, M.D. has been an emergency department physician for 25 years. Author of the book Runaway Medicine: What You Don’t Know May Kill You, she has written extensively about COVID-19 for national publications, including Fortune. Barber is co-founder of the California-based homeless work program Wheels of Change.
The opinions expressed in Fortune.com commentary pieces are solely the views of their authors and do not necessarily reflect the opinions and beliefs of Fortune.
