- Email: [email protected]
Commentary: What if?
INJURY PREVENTION/NHTSA NOTES
National Highway Traffic Safety Administration (NHTSA) Notes Commentator Todd Thoma, MD
From the Department of Emergency Medicine, Louisiana State University, Shreveport, LA.
Reprints not available from the editors.
The Increase in Lives Saved, Injuries Prevented, and Cost Savings if Seat Belt Use Rose to at Least 90 Percent in All States1 [National Highway Traffic Safety Administration. The increase in lives saved, injuries prevented, and cost savings if seat belt use rose to at least 90 percent in all states. Ann Emerg Med. 2009;54:837.] The National Highway Traffic Safety Administration (NHTSA) has examined the potential increase in lives saved, injuries prevented, and cost savings that would be realized if seat belt use hypothetically increased to at least 90% in all states. Estimates of lives saved and injuries prevented are based on 2007 seat belt usage rates as reported by the National Occupant Protection Usage Survey and published estimates of seat belt effectiveness. Estimates of cost savings include productivity losses, medical costs, rehabilitation costs, legal and court costs, emergency services (such as medical, police, and fire services), insurance administration costs, and the costs to employers. Values for more intangible consequences such as physical pain or lost quality of life are not included. A more detailed description of the methodology can be found in the report The Economic Impact of Motor Vehicle Crashes, 2000.2 Estimates of lives saved and total cost savings (in 2007 dollars) were also computed according to actual belt usage rates in each state. Seat belts saved an estimated 15,147 lives in 2007, when the estimated belt use was 82%. Currently, 38 states and the District of Columbia had a seat belt use rate below 90% in 2007. If usage rates in these states were increased to 90%, an estimated 1,652 additional lives could have been saved, and nearly 40,000 more nonfatal injuries would have been prevented, resulting in cost savings of about $5.2 billion. If seat belt use reached 100%, a total of 5,024 lives would have been saved, according to data from 2007. Nearly one third (32.9%) of these 5,024 potential lives saved would be achieved with each state improving its seat belt use to 90%. According to 2007 belt use data, it is estimated that seat belt usage resulted in savings of 15,147 lives and $74.4 billion. More than 50% of the total benefits in lives saved (842 of the total of 1,652 lives saved), nonfatal injuries prevented (22,677 of the total of 39,486 nonfatal injuries), and cost savings ($3.0 billion of the total of $5.2 billion) would come from states that currently do not have “primary enforcement” seat belt laws. An increase in seat belt use up to 90% would have saved in excess of $200 million each in 11 states in 2007, Volume , . : December
including Florida ($605 million), Massachusetts ($420 million), New York ($353 million), Ohio ($319 million), Louisiana ($274 million), Virginia ($262 million), Kentucky ($253 million), South Carolina ($247 million), Missouri ($239 million), Wisconsin ($221 million), and Tennessee ($208 million). Copies of the 4-page Research Note The Increase in Lives Saved, Injuries Prevented, and Cost Savings if Seat Belt Use Rose to at Least 90 Percent in All States can be obtained from the National Center for Statistics and Analysis, NHTSA,1200 New Jersey Avenue, SE, Washington, DC 20590 or downloaded from the NHTSA Web site at http://www-nrd.nhtsa.dot.gov/ Pubs/811140.PDF. doi:10.1016/j.annemergmed.2009.10.005
REFERENCES 1. National Highway Traffic Safety Administration. The Increase in Lives Saved, Injuries Prevented, and Cost Savings if Seat Belt Use Rose to at Least 90 Percent in All States. Washington, DC: US Dept of Transportation; 2008. Report No. DOT HS 811 140. 2. Blincoe LJ, Sea AG, Zaloshnja E, et al. The Economic Impact of Motor Vehicle Crashes 2000. Washington, DC: US Dept of Transportation; 2002. Report No. DOT HS 889 446. May be downloaded at: http://www-nrd.nhtsa.dot.gov/Pubs/809446.PDF.
COMMENTARY: WHAT IF? [Thoma TG. What if? Ann Emerg Med. 2009;54:837-839.] I sometimes look with great pride at the advances that have been made in traffic safety and occupant protection throughout the last several decades. When I remember that seat belt use was 14% back in 1984 and as of 2008, the seat belt use rates have increased to 83%,1 I get the feeling that we can sit back and reflect on a job well done. Through the efforts of multiple advertisement campaigns, the hard work and sweat of many agencies, and tireless dedication of community advocates and highway safety officials, many lives have been saved. The NHTSA’s National Center for Statistics and Analysis estimates that from 1975 to 2007, 241,789 lives have been saved by seat belts and another 8,709 lives were saved by child safety restraints.2 This is an impressive record and one that we all should be proud of . . . and then an article is published that asks, what if? This month’s article from the NHTSA titled “The Increase in Lives Saved, Injuries Prevented, and Cost Savings if Seat Belt Use Rose to at Least 90 Percent in All States” details that, although we have done a good job, continuing to increase seat belt use results in significant reduction in fatality and Annals of Emergency Medicine 837
NHTSA Notes morbidity rates and realizes a dramatic cost savings. This study examines 38 states and the District of Columbia, all of which in 2007 had seat belt use rates below 90%. The researchers looked at what the potential savings would be if these entities could increase their seat belt use rates to 90%. The study estimated that an additional 1,652 lives would have been saved had this increase in seat belt use occurred, and nearly 40,000 more nonfatal injuries would have been prevented, which would result in an additional cost savings of about $5.2 billion.3 In addition to health and wellness benefits to those individuals who were unharmed, 90% belt use in those areas would likely be 40,000 fewer emergency department (ED) visits, a potentially important effect on crowding and resource use in our day-to-day working lives. Now, imagine if seat belt use rates approached 100%. Research has shown that use of lap/shoulder belts reduces the risk of fatal injury to front-seat occupants by 45% and the risk of moderate to critical injury by 50%. These numbers are even higher for light-truck occupants, with a 60% reduction in fatality and a 65% reduction in moderate to critical injury. The use of seat belts has steadily increased since the National Occupant Protection Use Survey started collecting data in 1994 and found that the overall use rate for the nation was 58%. A careful look at passenger vehicle fatalities in 2007 reveals that, although the overall seat belt use was 82%, 54% of the fatalities were incurred by unrestrained vehicle occupants.2 A critical examination of these numbers reveals that 18% of the general population was unrestrained but these individuals accounted for more than half of the fatalities. Clearly, the unrestrained minority accounts for a disproportionate percentage of the fatalities. Restrained occupants fare better in motor vehicle crashes compared with their unrestrained counterparts. This is not surprising; seat belt use is central to optimal use of many other safety features built into automobiles. Let us take a vehicle traveling at 50 miles per hour that strikes a solid object. In this crash, the vehicle coming to a stop is the first phase of deceleration. The occupant of the vehicle is driven by Newtonian physics and will continue to travel at 50 miles per hour until hitting the hard, unyielding interior of the vehicle. The occupant coming to a stop is considered the second phase of deceleration. The internal organs of the occupants are also driven by physics and will continue to move according to the principles of motion until stopped by an outside force. This is considered the third phase of deceleration. Seat belts and airbags are designed to make the vehicle and the occupant decelerate at the same rate. The challenge to automobile engineers is to control the rate of deceleration. The reduction in speed divided by the time during which it takes place defines deceleration. Injuryproducing forces are proportional to the deceleration experienced by the occupant. Occupant protection aims at reducing these forces by spreading the occupant’s changes in 838 Annals of Emergency Medicine
speed over longer times.4 An airplane that crashes into a mountain at 300 miles per hour and the same airplane landing on a runway and coming to a gradual stop have the same change in velocity; the difference is the stopping distance. One scenario is not survivable and the other is quite comfortable. The same theory can be applied to automobiles. In the previous example, with a vehicle traveling 50 miles per hour and striking a stationary object, if the vehicle is too rigid and does not deform, the stopping distance is minimal and energy is high. If the vehicle is too soft, it will offer no resistance and the occupant will strike the solid object at impact speed. Today’s automobiles are designed with crumple zones that allow certain parts of the vehicle to crush, much like an accordion folds, during a crash. This is an attempt to control the rate of deceleration. Seat belts apply forces keeping the body more fixed to the seat. The belt helps the occupant “ride down” the crash, so the impact with the steering wheel or instrument panel is less likely or less severe.4 Airbags are considered supplemental restraint systems and are designed to be used as a complement to seat belts. Seat belts are also very effective in preventing ejection from a vehicle. Rollover crashes are common scenarios that send people to trauma centers. Ejection is one of the most dangerous events that can happen to a person in a crash. In fatal crashes in 2007, 76% of passenger vehicle occupants who were totally ejected from the vehicle were killed. If a person is properly wearing his or her seat belt, only 1% will be totally ejected compared with 31% of unrestrained occupants.2 Although an overall seat belt use rate of 83% is an admirable accomplishment, statistics show that there is considerable room for improvement. In 2007, 28,933 occupants of passenger vehicles (passenger cars, light trucks, vans, and sport utility vehicles) were killed in motor vehicle traffic crashes, 70% of the 41,059 traffic fatalities reported for the year. A breakdown of percentage of seat belt use by state shows a high of 97.6% in Hawaii to a low of 63.8% in New Hampshire.2 The relationship between crash risk, injury risk, and belt use is even more complex. Individuals who choose not to use a belt may be more likely to crash because of their increased willingness to take risks. This may put them in our EDs with a survivable injury related to a crash and provide a unique opportunity for prevention: reminding the patients that they may not have been injured if they had worn a belt. Many things have been shown to be effective in increasing seat belt use rates. One of the most effective has been primary seat belt laws.5 In states with these laws, law enforcement personnel can issue a ticket to unrestrained occupants simply for not buckling up. In states with secondary seat belt laws, citations for not using a seat belt can be given only when a driver is stopped for another offense. Currently, there are 30 states with primary seat belt laws and 19 states with secondary seat belt laws. New Hampshire is the only state that has no primary or secondary law for adults, but they do have a primary child passenger safety law that covers children younger than 18 Volume , . : December
NHTSA Notes years.6 In 2007, seat belt use rates were 87% in primary law states versus 73% in secondary law states. On average, states that pass primary seat belt laws can expect an increase in seat belt use of 9 percentage points.5 Campaigns such as Buckle Up America and Click It or Ticket, combined with high-visibility enforcement, have also been shown to be very effective in increasing seat belt use rates. As members of the medical community who see the tragic results of crashes involving unrestrained vehicle occupants, we can help with promotion of public information and education about the benefits of buckling up and the consequences of not doing so. As emergency physicians, we are often placed in a unique position to educate and potentially effect a change in behavior. Although intervention would be too late for many, the opportunity exists for the education of survivors and family members. A visit to the ED after a crash involving unrestrained vehicle occupants presents itself as a teachable moment. It is my experience that this is a time when victims will listen. Explaining to unrestrained occupants how their injuries could have been lessened or reasserting to seat belt users how restraints may have saved their lives could result in lifelong behavioral change. Victims often share this information with family,
friends, and colleagues. A few extra minutes out of a busy shift could save lives. Section editors: Chris Kahn, MD, MPH; Mary Pat McKay, MD, MPH; Todd Thoma, MD, MPH; Catherine S. Gotschall, ScD REFERENCES 1. National Highway Traffic Safety Administration. Seat Belt Use in 2008: Overall Results. Washington, DC: US Dept of Transportation; 2008. Report No. DOT HS 811 036. 2. National Highway Traffic Safety Administration. Occupant Protection. Washington, DC: US Dept of Transportation; 2007. Report No. DOT HS 810 991. 3. National Highway Traffic Safety Administration. The Increase in Lives Saved, Injuries Prevented, and Cost Savings if Seat Belt Use Rose to at Least 90 Percent in All States. Washington, DC: US Dept of Transportation; 2009. Report No. DOT HS 811 140. 4. Evans L. Occupant protection. Traffic Safety. 2004;270-273. 5. National Highway Traffic Safety Administration. Strengthening Seat Belt Use Laws. Washington, DC: US Dept of Transportation; 2008. Report No. DOT HS 810 890W. 6. Governors Highway Safety Association. Seat Belt Laws. August 2009. 444 N. Capitol St Suite 722. Washington DC, 20001. doi:10.1016/j.annemergmed.2009.10.006
Access to Annals of Emergency Medicine Online is now reserved for ACEP members and print subscribers. Full-text access to Annals of Emergency Medicine Online is now available for ACEP members and all print subscribers. To activate your individual online subscription, please visit Annals of Emergency Medicine Online by pointing your browser to http://www.annemergmed.com, follow the prompts to activate your online access, and follow the instructions. To activate your account, you will need your ACEP member number or your subscriber account number, which you can find on your mailing label. If you need further assistance to access the online journal, please contact Periodicals Services at 800-654-2452. Personal subscriptions to Annals of Emergency Medicine Online are for individual use only and may not be transferred. Use of Annals of Emergency Medicine Online is subject to agreement to the terms and conditions as indicated online. Information is also available at ACEP’s home page at www.acep.org.
Volume , . : December
Annals of Emergency Medicine 839
National Highway Traffic Safety Administration (NHTSA) Notes Commentator Todd Thoma, MD
From the Department of Emergency Medicine, Louisiana State University, Shreveport, LA.
Reprints not available from the editors.
The Increase in Lives Saved, Injuries Prevented, and Cost Savings if Seat Belt Use Rose to at Least 90 Percent in All States1 [National Highway Traffic Safety Administration. The increase in lives saved, injuries prevented, and cost savings if seat belt use rose to at least 90 percent in all states. Ann Emerg Med. 2009;54:837.] The National Highway Traffic Safety Administration (NHTSA) has examined the potential increase in lives saved, injuries prevented, and cost savings that would be realized if seat belt use hypothetically increased to at least 90% in all states. Estimates of lives saved and injuries prevented are based on 2007 seat belt usage rates as reported by the National Occupant Protection Usage Survey and published estimates of seat belt effectiveness. Estimates of cost savings include productivity losses, medical costs, rehabilitation costs, legal and court costs, emergency services (such as medical, police, and fire services), insurance administration costs, and the costs to employers. Values for more intangible consequences such as physical pain or lost quality of life are not included. A more detailed description of the methodology can be found in the report The Economic Impact of Motor Vehicle Crashes, 2000.2 Estimates of lives saved and total cost savings (in 2007 dollars) were also computed according to actual belt usage rates in each state. Seat belts saved an estimated 15,147 lives in 2007, when the estimated belt use was 82%. Currently, 38 states and the District of Columbia had a seat belt use rate below 90% in 2007. If usage rates in these states were increased to 90%, an estimated 1,652 additional lives could have been saved, and nearly 40,000 more nonfatal injuries would have been prevented, resulting in cost savings of about $5.2 billion. If seat belt use reached 100%, a total of 5,024 lives would have been saved, according to data from 2007. Nearly one third (32.9%) of these 5,024 potential lives saved would be achieved with each state improving its seat belt use to 90%. According to 2007 belt use data, it is estimated that seat belt usage resulted in savings of 15,147 lives and $74.4 billion. More than 50% of the total benefits in lives saved (842 of the total of 1,652 lives saved), nonfatal injuries prevented (22,677 of the total of 39,486 nonfatal injuries), and cost savings ($3.0 billion of the total of $5.2 billion) would come from states that currently do not have “primary enforcement” seat belt laws. An increase in seat belt use up to 90% would have saved in excess of $200 million each in 11 states in 2007, Volume , . : December
including Florida ($605 million), Massachusetts ($420 million), New York ($353 million), Ohio ($319 million), Louisiana ($274 million), Virginia ($262 million), Kentucky ($253 million), South Carolina ($247 million), Missouri ($239 million), Wisconsin ($221 million), and Tennessee ($208 million). Copies of the 4-page Research Note The Increase in Lives Saved, Injuries Prevented, and Cost Savings if Seat Belt Use Rose to at Least 90 Percent in All States can be obtained from the National Center for Statistics and Analysis, NHTSA,1200 New Jersey Avenue, SE, Washington, DC 20590 or downloaded from the NHTSA Web site at http://www-nrd.nhtsa.dot.gov/ Pubs/811140.PDF. doi:10.1016/j.annemergmed.2009.10.005
REFERENCES 1. National Highway Traffic Safety Administration. The Increase in Lives Saved, Injuries Prevented, and Cost Savings if Seat Belt Use Rose to at Least 90 Percent in All States. Washington, DC: US Dept of Transportation; 2008. Report No. DOT HS 811 140. 2. Blincoe LJ, Sea AG, Zaloshnja E, et al. The Economic Impact of Motor Vehicle Crashes 2000. Washington, DC: US Dept of Transportation; 2002. Report No. DOT HS 889 446. May be downloaded at: http://www-nrd.nhtsa.dot.gov/Pubs/809446.PDF.
COMMENTARY: WHAT IF? [Thoma TG. What if? Ann Emerg Med. 2009;54:837-839.] I sometimes look with great pride at the advances that have been made in traffic safety and occupant protection throughout the last several decades. When I remember that seat belt use was 14% back in 1984 and as of 2008, the seat belt use rates have increased to 83%,1 I get the feeling that we can sit back and reflect on a job well done. Through the efforts of multiple advertisement campaigns, the hard work and sweat of many agencies, and tireless dedication of community advocates and highway safety officials, many lives have been saved. The NHTSA’s National Center for Statistics and Analysis estimates that from 1975 to 2007, 241,789 lives have been saved by seat belts and another 8,709 lives were saved by child safety restraints.2 This is an impressive record and one that we all should be proud of . . . and then an article is published that asks, what if? This month’s article from the NHTSA titled “The Increase in Lives Saved, Injuries Prevented, and Cost Savings if Seat Belt Use Rose to at Least 90 Percent in All States” details that, although we have done a good job, continuing to increase seat belt use results in significant reduction in fatality and Annals of Emergency Medicine 837
NHTSA Notes morbidity rates and realizes a dramatic cost savings. This study examines 38 states and the District of Columbia, all of which in 2007 had seat belt use rates below 90%. The researchers looked at what the potential savings would be if these entities could increase their seat belt use rates to 90%. The study estimated that an additional 1,652 lives would have been saved had this increase in seat belt use occurred, and nearly 40,000 more nonfatal injuries would have been prevented, which would result in an additional cost savings of about $5.2 billion.3 In addition to health and wellness benefits to those individuals who were unharmed, 90% belt use in those areas would likely be 40,000 fewer emergency department (ED) visits, a potentially important effect on crowding and resource use in our day-to-day working lives. Now, imagine if seat belt use rates approached 100%. Research has shown that use of lap/shoulder belts reduces the risk of fatal injury to front-seat occupants by 45% and the risk of moderate to critical injury by 50%. These numbers are even higher for light-truck occupants, with a 60% reduction in fatality and a 65% reduction in moderate to critical injury. The use of seat belts has steadily increased since the National Occupant Protection Use Survey started collecting data in 1994 and found that the overall use rate for the nation was 58%. A careful look at passenger vehicle fatalities in 2007 reveals that, although the overall seat belt use was 82%, 54% of the fatalities were incurred by unrestrained vehicle occupants.2 A critical examination of these numbers reveals that 18% of the general population was unrestrained but these individuals accounted for more than half of the fatalities. Clearly, the unrestrained minority accounts for a disproportionate percentage of the fatalities. Restrained occupants fare better in motor vehicle crashes compared with their unrestrained counterparts. This is not surprising; seat belt use is central to optimal use of many other safety features built into automobiles. Let us take a vehicle traveling at 50 miles per hour that strikes a solid object. In this crash, the vehicle coming to a stop is the first phase of deceleration. The occupant of the vehicle is driven by Newtonian physics and will continue to travel at 50 miles per hour until hitting the hard, unyielding interior of the vehicle. The occupant coming to a stop is considered the second phase of deceleration. The internal organs of the occupants are also driven by physics and will continue to move according to the principles of motion until stopped by an outside force. This is considered the third phase of deceleration. Seat belts and airbags are designed to make the vehicle and the occupant decelerate at the same rate. The challenge to automobile engineers is to control the rate of deceleration. The reduction in speed divided by the time during which it takes place defines deceleration. Injuryproducing forces are proportional to the deceleration experienced by the occupant. Occupant protection aims at reducing these forces by spreading the occupant’s changes in 838 Annals of Emergency Medicine
speed over longer times.4 An airplane that crashes into a mountain at 300 miles per hour and the same airplane landing on a runway and coming to a gradual stop have the same change in velocity; the difference is the stopping distance. One scenario is not survivable and the other is quite comfortable. The same theory can be applied to automobiles. In the previous example, with a vehicle traveling 50 miles per hour and striking a stationary object, if the vehicle is too rigid and does not deform, the stopping distance is minimal and energy is high. If the vehicle is too soft, it will offer no resistance and the occupant will strike the solid object at impact speed. Today’s automobiles are designed with crumple zones that allow certain parts of the vehicle to crush, much like an accordion folds, during a crash. This is an attempt to control the rate of deceleration. Seat belts apply forces keeping the body more fixed to the seat. The belt helps the occupant “ride down” the crash, so the impact with the steering wheel or instrument panel is less likely or less severe.4 Airbags are considered supplemental restraint systems and are designed to be used as a complement to seat belts. Seat belts are also very effective in preventing ejection from a vehicle. Rollover crashes are common scenarios that send people to trauma centers. Ejection is one of the most dangerous events that can happen to a person in a crash. In fatal crashes in 2007, 76% of passenger vehicle occupants who were totally ejected from the vehicle were killed. If a person is properly wearing his or her seat belt, only 1% will be totally ejected compared with 31% of unrestrained occupants.2 Although an overall seat belt use rate of 83% is an admirable accomplishment, statistics show that there is considerable room for improvement. In 2007, 28,933 occupants of passenger vehicles (passenger cars, light trucks, vans, and sport utility vehicles) were killed in motor vehicle traffic crashes, 70% of the 41,059 traffic fatalities reported for the year. A breakdown of percentage of seat belt use by state shows a high of 97.6% in Hawaii to a low of 63.8% in New Hampshire.2 The relationship between crash risk, injury risk, and belt use is even more complex. Individuals who choose not to use a belt may be more likely to crash because of their increased willingness to take risks. This may put them in our EDs with a survivable injury related to a crash and provide a unique opportunity for prevention: reminding the patients that they may not have been injured if they had worn a belt. Many things have been shown to be effective in increasing seat belt use rates. One of the most effective has been primary seat belt laws.5 In states with these laws, law enforcement personnel can issue a ticket to unrestrained occupants simply for not buckling up. In states with secondary seat belt laws, citations for not using a seat belt can be given only when a driver is stopped for another offense. Currently, there are 30 states with primary seat belt laws and 19 states with secondary seat belt laws. New Hampshire is the only state that has no primary or secondary law for adults, but they do have a primary child passenger safety law that covers children younger than 18 Volume , . : December
NHTSA Notes years.6 In 2007, seat belt use rates were 87% in primary law states versus 73% in secondary law states. On average, states that pass primary seat belt laws can expect an increase in seat belt use of 9 percentage points.5 Campaigns such as Buckle Up America and Click It or Ticket, combined with high-visibility enforcement, have also been shown to be very effective in increasing seat belt use rates. As members of the medical community who see the tragic results of crashes involving unrestrained vehicle occupants, we can help with promotion of public information and education about the benefits of buckling up and the consequences of not doing so. As emergency physicians, we are often placed in a unique position to educate and potentially effect a change in behavior. Although intervention would be too late for many, the opportunity exists for the education of survivors and family members. A visit to the ED after a crash involving unrestrained vehicle occupants presents itself as a teachable moment. It is my experience that this is a time when victims will listen. Explaining to unrestrained occupants how their injuries could have been lessened or reasserting to seat belt users how restraints may have saved their lives could result in lifelong behavioral change. Victims often share this information with family,
friends, and colleagues. A few extra minutes out of a busy shift could save lives. Section editors: Chris Kahn, MD, MPH; Mary Pat McKay, MD, MPH; Todd Thoma, MD, MPH; Catherine S. Gotschall, ScD REFERENCES 1. National Highway Traffic Safety Administration. Seat Belt Use in 2008: Overall Results. Washington, DC: US Dept of Transportation; 2008. Report No. DOT HS 811 036. 2. National Highway Traffic Safety Administration. Occupant Protection. Washington, DC: US Dept of Transportation; 2007. Report No. DOT HS 810 991. 3. National Highway Traffic Safety Administration. The Increase in Lives Saved, Injuries Prevented, and Cost Savings if Seat Belt Use Rose to at Least 90 Percent in All States. Washington, DC: US Dept of Transportation; 2009. Report No. DOT HS 811 140. 4. Evans L. Occupant protection. Traffic Safety. 2004;270-273. 5. National Highway Traffic Safety Administration. Strengthening Seat Belt Use Laws. Washington, DC: US Dept of Transportation; 2008. Report No. DOT HS 810 890W. 6. Governors Highway Safety Association. Seat Belt Laws. August 2009. 444 N. Capitol St Suite 722. Washington DC, 20001. doi:10.1016/j.annemergmed.2009.10.006
Access to Annals of Emergency Medicine Online is now reserved for ACEP members and print subscribers. Full-text access to Annals of Emergency Medicine Online is now available for ACEP members and all print subscribers. To activate your individual online subscription, please visit Annals of Emergency Medicine Online by pointing your browser to http://www.annemergmed.com, follow the prompts to activate your online access, and follow the instructions. To activate your account, you will need your ACEP member number or your subscriber account number, which you can find on your mailing label. If you need further assistance to access the online journal, please contact Periodicals Services at 800-654-2452. Personal subscriptions to Annals of Emergency Medicine Online are for individual use only and may not be transferred. Use of Annals of Emergency Medicine Online is subject to agreement to the terms and conditions as indicated online. Information is also available at ACEP’s home page at www.acep.org.
Volume , . : December
Annals of Emergency Medicine 839