Local Medical Examiners Research Articles

Alcohol and drug presence in traffic crash fatalities before and after the COVID-19 pandemic: Evaluation of the fatality analysis reporting system (FARS) and linked medical examiner-vital records data in Clackamas, Multnomah, and Washington County, Oregon, 2019–2021

Traffic fatalities, with and from increased risky behaviors (reduced seat belt use, increased impairment from licit and illicit substances), have been increasing, especially during the COVID-19 pandemic. Death certificates are a major source of epidemiologic data in the United States, but have known underreporting of drug and alcohol presence. The Fatality Analysis Reporting System (FARS) is one major source of data on fatal crashes with intoxication. This study links FARS data for three counties in Oregon (2019–2021) with local medical examiner and death certificate data (FARS source data) and compares their concordance with blood alcohol concentration and toxicology for three major drug classes by year. For drivers only, our study finds good concordance between FARS and its source data in 2019 but poor concordance in 2020. This discordance may impact future analysis of impaired crash deaths, and we list some suggestions for amelioration.

Examining Increasing Racial Inequities in Opioid Overdose Deaths: a Spatiotemporal Analysis of Black and White Decedents in St. Louis, Missouri, 2011-2021.

The third wave of the opioid overdose crisis-defined by the proliferation of illicit fentanyl and its analogs-has not only led to record numbers of overdose deaths but also to unprecedented racial inequities in overdose deaths impacting Black Americans. Despite this racialized shift in opioid availability, little research has examined how the spatial epidemiology of opioid overdose death has also shifted. The current study examines the differential geography of OOD by race and time (i.e., pre-fentanyl versus fentanyl era) in St. Louis, Missouri. Data included decedent records from the local medical examiners suspected to involve opioid overdose (N = 4420). Analyses included calculating spatial descriptive analyses and conducting hotspot analyses (i.e., Gettis-Ord Gi*) stratified by race (Black versus White) and time (2011-2015 versus 2016-2021). Results indicated that fentanyl era overdose deaths were more densely clustered than pre-fentanyl era deaths, particularly those among Black decedents. Although hotspots of overdose death were racially distinct pre-fentanyl, they substantially overlapped in the fentanyl era, with both Black and White deaths clustering in predominantly Black neighborhoods. Racial differences were observed in substances involved in cause of death and other overdose characteristics. The third wave of the opioid crisis appears to involve a geographic shift from areas where White individuals live to those where Black individuals live. Findings demonstrate racial differences in the epidemiology of overdose deaths that point to built environment determinants for future examination. Policy interventions targeting high-deprivation communities are needed to reduce the burden of opioid overdose on Black communities.

Current utilization of pediatric postmortem imaging in North America: a questionnaire-based survey.

Postmortem imaging is used more widely as the number of conventional autopsies has decreased over the last several decades. It is widely accepted in Europe, Asia and Oceania, but there has been a delay in acceptance in North America. Education, scanning protocols, resourcing and clinical incentives are needed to support this emerging field. To determine the use of postmortem imaging and define perceived barriers to its implementation with the goal of expanding postmortem imaging in the United States and Canada. We sent an online survey to active members of the Society for Pediatric Radiology (SPR) addressing the use of postmortem imaging, indications, readers, practical aspects, anticipated barriers and potential solutions to more widespread use. More than 50% of the 50 institutions that returned surveys used postmortem computed tomography; 24% used postmortem magnetic resonance imaging. Most postmortem imaging cases were read by radiologists. Fewer than 50% had formal correlation with autopsy results or an established relationship with the local medical examiner. Seven institutions reported reimbursement for postmortem imaging. Major barriers to postmortem imaging included lack of funding and lack of interest among clinicians. Funding and education were seen as important issues requiring attention. While most responding institutions provide pediatric postmortem imaging, the modalities, protocols, reporting procedures and clinical correlation vary widely. A lack of funding and few opportunities for education are limiting factors. Attention to these issues along with active support from the SPR are seen as potential solutions to recognize the value and promote widespread acceptance of postmortem imaging.

POLICING FORENSIC EVIDENCE

POLICING FORENSIC EVIDENCE

Incidence of recreational sports-related sudden cardiac arrest in participants over age 12 in a general African population

BackgroundThe incidence of sports-related sudden cardiac arrest (SrSCA) in sub-Saharan Africa is unknown.ObjectiveTo determine the incidence of sudden cardiac arrest (SCA) in non-competitive athletes in an urban population of Cameroon,...

Overdose Deaths Involving Fentanyl and Fentanyl Analogs — New York City, 2000–2017

Unintentional drug overdose deaths have climbed to record high levels, claiming approximately 70,000 lives in the United States in 2017 alone (1). The emergence of illicitly manufactured fentanyl* (a synthetic, short-acting opioid with 50-100 times the potency of morphine) mixed into heroin, cocaine, and counterfeit pills, with or without the users' knowledge, has increased the risk for fatal overdose (2,3). The New York City (NYC) Department of Health and Mental Hygiene (DOHMH) conducts routine overdose mortality surveillance by linking death certificates with toxicology findings from the NYC Office of the Chief Medical Examiner (OCME). A 55% increase in the rate of fatal drug overdose in NYC was observed from 2015 to 2017, resulting in the highest number of overdose deaths recorded since systematic reporting began in 2000. Toxicology data indicate that this unprecedented increase in overdose deaths is attributable to fentanyl. Early identification of increased fentanyl involvement enabled DOHMH to respond rapidly to the opioid overdose epidemic by increasing awareness of the risks associated with fentanyl and developing effective risk reduction messaging. These results strongly suggest that, wherever possible, jurisdictions should consider integrating toxicology findings into routine overdose surveillance and work with local medical examiners or coroners to include fentanyl in the literal text on death certificates.

Identifying Unreported Opioid Deaths Through Toxicology Data and Vital Records Linkage: Case Study in Marion County, Indiana, 2011-2016.

To demonstrate the severity of undercounting opioid-involved deaths in a local jurisdiction with a high proportion of unspecified accidental poisoning deaths. We matched toxicology data to vital records for all accidental poisoning deaths (n = 1238) in Marion County, Indiana, from January 2011 to December 2016. From vital records, we coded cases as opioid involved, specified other substance, or unspecified. We extracted toxicology data on opioid substances for unspecified cases, and we have reported corrected estimates of opioid-involved deaths after accounting for toxicology findings. Over a 6-year period, 57.7% of accidental overdose deaths were unspecified and 34.2% involved opioids. Toxicology data showed that 86.8% of unspecified cases tested positive for an opioid. Inclusion of toxicology results more than doubled the proportion of opioid-involved deaths, from 34.2% to 86.0%. Local jurisdictions may be undercounting opioid-involved overdose deaths to a considerable degree. Toxicology data can improve accuracy in identifying opioid-involved overdose deaths. Public Health Implications. Mandatory toxicology testing and enhanced training for local coroners on standards for death certificate reporting are needed to improve the accuracy of local monitoring of opioid-involved accidental overdose deaths.

Sport-related sudden cardiac arrest in black African non-competitive athletes: Incidence in a general population of Cameroon

Incidence estimates of sudden cardiac arrest (SCA) in athletes living in sub-Saharan Africa (SSA) are unknown. Over 12 months, the household administrative office and health community committee within neighbourhoods in two health areas of Douala (Cameroon) registered all deaths among 86,188 inhabitants aged under 18 years. As part of an extended multi-source surveillance system, all sport fields, the Emergency Medical Service (EMS), local medical examiners and district hospital mortuaries were also surveyed. Whereas two physicians investigated every natural death, two cardiologists reviewed all unexpected natural deaths. There were 288 all-cause deaths and 27 (9.4%) were SCD. The crude incidence rate was 31.3 [95% confidence interval (CI): 20.3–40.6]/100,000 person–years. The age-standardized rate by the African standard population was 33.6 (95% CI: 22.4–44.9)/100,000 person–years. Death occurred at night in 37% of cases, including 11% of patients who died while asleep. Out-of-hospital SCA occurred in 63% of cases, 55.5% of which occurred at home. Of the 88.9% cases of witnessed CA, 63% occurred in the presence of a family member and cardiopulmonary resuscitation was attempted only in 3.7%. While running, death occurred in 1 (3.7%) non-competitive female athlete aged 35 years. Sport-related SCA in this African population claimed an annual incidence of 1.15 cases per 100,000 person–years, which is in accordance with reported rates in the literature. Long-term cohort studies in many African countries are warranted to better understand incidence estimates of SCA in black athletes.

Epidemiology of sudden cardiac death in Cameroon: the first population-based cohort survey in sub-Saharan Africa.

BackgroundIncidence estimates of sudden cardiac death (SCD) in sub-Saharan Africa (SSA) are unknown.MethodOver 12 months, the household administrative office and health community committee within neighbourhoods in two health areas of Douala, Cameroon, registered all deaths among 86 188 inhabitants aged >18 years. As part of an extended multi-source surveillance system, the Emergency Medical Service (EMS), local medical examiners and district hospital mortuaries were also surveyed. Whereas two physicians investigated every natural death, two cardiologists reviewed all unexpected natural deaths.ResultsThere were 288 all-cause deaths and 27 (9.4%) were SCD. The crude incidence rate was 31.3 [95% confidence interval (CI): 20.3–40.6]/100 000 person-years. The age-standardized rate by the African standard population was 33.6 (95% CI: 22.4–44.9)/100 000 person-years. Death occurred at night in 37% of cases, including 11% of patients who died while asleep. Out-of-hospital sudden cardiac arrest occurred in 63% of cases, 55.5% of which occurred at home. Of the 88.9% cases of witnessed cardiac arrest, 63% occurred in the presence of a family member and cardiopulmonary resuscitation was attempted only in 3.7%.ConclusionThe burden of SCD in this African population is heavy with distinct characteristics, whereas awareness of SCD and prompt resuscitation efforts appear suboptimal. Larger epidemiological studies are required in SSA in order to implement preventive measures, especially in women and young people.

Point/Counterpoint: Opioid Abuse in the United States

Point/Counterpoint: Opioid Abuse in the United States

Mechanical testing of patellofemoral instability after induced failure of the patellofemoral ligament reconstruction using four differents cadavers grafts

PurposeTo ascertain whether differences exist in joint instability after experimentally induced failure of medial patellofemoral ligament (MPFL) reconstruction in the cadaver knee with the four graft types most widely used for this procedure, and whether any of these grafts are associated with decreased risk in the event of failure. MethodsBetween March 2011 and March 2012, eight cadavers obtained from the local medical examiner's office were randomly allocated into four groups (four knees each). In each group, a different graft technique was used for MPFL reconstruction. The forces required to induce lateral dislocation of the patella before reconstruction and after experimental failure of surgical reconstruction were recorded. The tested graft techniques were then compared to assess which was associated with the least instability after failed reconstruction. ResultsWhen we compared the groups I (semitendinosus) and II (patellar tendon), the mean differences of the force required to produce a dislocation of the patella before and after the failure were 0.5 N and 12.5 N, respectively (p = 0.028). In comparison between groups I and III (medial third of the quadriceps tendon) the mean differences of the force required to produce dislocation before and after the failure caused were 0.5 N and 22 N, respectively (p < 0.001). In comparison between groups I and IV (Medial third of the quadriceps tendon) we found the mean differences of the force required to produce dislocation before and after the failure caused were 0.5 N and 5 N, respectively (p > 0.999). ConclusionsThere were differences in residual instability after simulated MPFL reconstruction failure depending on graft type. Use of the free semitendinosus graft technique was associated with the least risk of residual instability in case of reconstruction failure.

Sudden Unexpected Infant Death

Sudden unexpected infant deaths (SUIDs) are deaths in infants younger than 12 months that occur suddenly, unexpectedly, and without obvious cause in the emergency department (ED). Sudden infant death syndrome, the leading cause of SUID in the United States, is much more common, but fatal child abuse and neglect have been sometimes mistaken for sudden infant death syndrome. The distinction between these 2 entities can only be made after a thorough investigation of the scene, interview of caregivers, and a complete forensic autopsy. Development of ED guidelines for the reporting and evaluation of SUID, in collaboration with the local medical examiner and child death review teams, will enable ED practitioners to collect important information in a compassionate manner that will be valuable to the investigating personnel.

Shortcomings of Urine-Preferred Drug Screening on Post-Mortem Specimens

Abstract In counties with limited budgets, in order to save money on toxicology work, the request often comes from local medical examiners that screening for drugs on decedents be performed initially on urine and, if positive, to send blood for confirmation; negative urine results are not further evaluated. A study of known urine and blood drug screens was performed to evaluate the clinical and cost-effectiveness of this practice. Results of 401 autopsies were reviewed. In all, 11 decedents had both urine and blood drug screens performed. There were seven men and four women, mean age for both 39 years. In the urine drug screens, there were nine true positive tests, 17 false positives, 45 true negatives, and five false negatives; sensitivity 64%, specificity 73%. The savings in cost were theoretically 34%, but screening urine for drugs on post-mortem specimens does not appear to be an effective way to determine what drugs were present at the time of death. It is inexpensive, however. Still, in a screening practice for which so many of the results are not reliable, one must decide whether the money saved is worth the misleading results. Considering how many critical decisions about cause and manner of death are based on toxicology, it would seem unreliable to choose a urine-preferred practice.

Coroners and death certification law reform: the Coroners and Justice Act 2009 and its aftermath

After considering various different options for half a decade, the last Government legislated in 2009 to reform the England and Wales coroner and death certification systems. The Coroners and Justice Act 2009 provides for the creation of a new Chief Coroner post to lead the jurisdiction and for local medical examiners to oversee a new death certification scheme applicable equally to burial and cremation cases. In October 2010 the new Government announced that it judges the main coroner reform to be unaffordable, will not proceed with it and plans to repeal the provisions. It intends to implement the new death certification arrangements, which is welcome. The decision to abort the main coroner reform in spite of longstanding and widespread recognition of the need for major change is deplorable though in line with other failures over the last century to properly modernise this neglected service.

Studying Sudden and Unexpected Infant Deaths in a Time of Changing Death Certification and Investigation Practices: Evaluating Sleep-Related Risk Factors for Infant Death in New York City

We describe an approach for quantifying and characterizing the extent to which sudden and unexpected infant deaths (SUIDs) result from unsafe sleep environments (e.g., prone position, bedsharing, soft bedding); and present data on sleep-related infant deaths in NYC. Using a combination of vital statistics and medical examiner data, including autopsy and death scene investigation findings, we analyzed any death due to accidental threat to breathing (ATB) (ICD-10 W75 & W84), and deaths of undetermined intent (UND) (Y10-Y34) between 2000 and 2003 in NYC for the presence of sleep-related factors (SRF). Homicide deaths were excluded as were SIDS, since in NYC SIDS is not a certification option if environmental factors were possibly contributors to the death. All 19 ATB and 69 (75%) UND had SRFs as per the OCME investigation. Black infants and infants born to teen mothers had higher SRF death rates for both ATB and UND deaths. Bedsharing was the most common SRF (53%-ATB; 72%-UND deaths); the majority of non-bedsharing infants were found in the prone position (60%-ATB; 78%-UND deaths). We found a high prevalence of SRFs among ATB and UND deaths. This is the first local study to illustrate the importance of knowing how SUIDs are certified in order to ascertain the prevalence of infant deaths with SRFs. Advancing the research requires clarity on the criteria used by local medical examiners to categorize SUIDs. This will help jurisdictions interpret their infant mortality statistics, which in turn will improve education and prevention efforts.

Forensic Anthropology

Previous articleNext article FreeCurrent ApplicationsForensic AnthropologyE.R.WaymanE.R.Wayman Search for more articles by this author PDFPDF PLUSFull Text Add to favoritesDownload CitationTrack CitationsPermissionsReprints Share onFacebookTwitterLinked InRedditEmailQR Code SectionsMoreIdentifying Bodies and Reuniting FamiliesHundreds of thousands of Mexicans cross the U.S.Mexican border into the United States annually, often seeking employment. Each year hundreds of these individuals die in the attempt. Because many of them have made the journey without identification or documentation, it is extremely difficult for officials to identify them when their bodies are discovered on the U.S. side of the border.Lori Baker, assistant professor of anthropology and forensic science at Baylor University in Texas, is working toward finding a way to provide names for these individuals/bodies. Applying her knowledge and expertise in DNA analysis to the situation, she is trying to identify as many bodies as she can.Bakers academic research uses the analysis of ancient DNA to study the peopling of the New World. Therefore, Baker is better prepared than local medical examiners to analyze the DNA of decaying bodies. As she explained during a telephone interview, county medical examiners cannot solve all of these border cases because they dont have the money and they dont have the laboratories in mtDNA or bone DNA.Baker first began applying her knowledge of forensics to body identification while doing human rights work in Central and South America during graduate school. In Peru, she recalled, everyone was appalled by the U.S.Mexico border situationthat nothing [was] being done to identify people. When she joined the faculty at Baylor University in 2002, she had the opportunity to be in close proximity to the U.S.Mexico border and to use her forensic skills to help correct this problem.For Baker, the granddaughter of a migrant worker, this work is especially meaningful. She considers it important not only to offer families closure but also to give them the opportunity to have their stories told. With that in mind, she initially thought that exhuming graves and solving cases would be just a summer project. That was before she discovered the true magnitude of the problem. With the help of her husband, Erich Baker, an assistant professor of computer science at Baylor, she has created a database of unidentified bodies found near the border. She collects DNA samples from these bodies and records them in her database. She also records an individuals physical attributes, including clothing. The Bakers have created a web site, http://www.reunitingfamilies.org, through which the database can be accessed. By visiting the web site, family members can search the database for a description that matches their missing relative. When they find a match, they can send Baker a DNA sample from a maternal relative. She then analyzes the mtDNA to determine whether the body is a match.During the first three years after the databases creation, Baker had solved one case in Pima County, Arizona, when she identified the remains of Rosa Cano, a 31yearold woman from Mexico's Yucatn Penninsula, and there were more than 7080 cases waiting to be entered into the database from Pima County alone. The volume of cases is too great for one person to handle. Baker points out that it is difficult for many of these families, who often do not have access to a telephone, let alone the Internet, to access the database. Fortunately, the Mexican government has recently offered her some assistance, both contributing to the cost of the testing and helping families to access the database. With this support she intends to continue her work and has already solved three more cases.Identification card, found under a barbed wire fence along the road near the border town of Douglas, Arizona, of an 18yearold Mexican man. (Photo Orlando Lara)View Large ImageDownload PowerPoint Previous articleNext article DetailsFiguresReferencesCited by Current Anthropology Volume 47, Number 1February 2006 Sponsored by the Wenner-Gren Foundation for Anthropological Research Article DOIhttps://doi.org/10.1086/498951 Views: 83 PDF download Crossref reports no articles citing this article.

Early violent death among delinquent youth: a prospective longitudinal study.

Youth processed in the juvenile justice system are at great risk for early violent death. Groups at greatest risk, ie, racial/ethnic minorities, male youth, and urban youth, are overrepresented in the juvenile justice system. We compared mortality rates for delinquent youth with those for the general population, controlling for differences in gender, race/ethnicity, and age. This prospective longitudinal study examined mortality rates among 1829 youth (1172 male and 657 female) enrolled in the Northwestern Juvenile Project, a study of health needs and outcomes of delinquent youth. Participants, 10 to 18 years of age, were sampled randomly from intake at the Cook County Juvenile Temporary Detention Center in Chicago, Illinois, between 1995 and 1998. The sample was stratified according to gender, race/ethnicity (African American, non-Hispanic white, Hispanic, or other), age (10-13 or > or =14 years), and legal status (processed as a juvenile or as an adult), to obtain enough participants for examination of key subgroups. The sample included 1005 African American (54.9%), 296 non-Hispanic white (16.2%), 524 Hispanic (28.17%), and 4 other-race/ethnicity (0.2%) subjects. The mean age at enrollment was 14.9 years (median age: 15 years). The refusal rate was 4.2%. As of March 31, 2004, we had monitored participants for 0.5 to 8.4 years (mean: 7.1 years; median: 7.2 years; interquartile range: 6.5-7.8 years); the aggregate exposure for all participants was 12944 person-years. Data on deaths and causes of death were obtained from family reports or records and were then verified by the local medical examiner or the National Death Index. For comparisons of mortality rates for delinquents and the general population, all data were weighted according to the racial/ethnic, gender, and age characteristics of the detention center; these weighted standardized populations were used to calculate reported percentages and mortality ratios. We calculated mortality ratios by comparing our sample's mortality rates with those for the general population of Cook County, controlling for differences in gender, race/ethnicity, and age. Sixty-five youth died during the follow-up period. All deaths were from external causes. As determined by using the weighted percentages to estimate causes of death, 95.5% of deaths were homicides or legal interventions (90.1% homicides and 5.4% legal interventions), 1.1% of all deaths were suicides, 1.3% were from motor vehicle accidents, 0.5% were from other accidents, and 1.6% were from other external causes. Among homicides, 93.0% were from gunshot wounds. The overall mortality rate was >4 times the general-population rate. The mortality rate among female youth was nearly 8 times the general-population rate. African American male youth had the highest mortality rate (887 deaths per 100000 person-years). Early violent death among delinquent and general-population youth affects racial/ethnic minorities disproportionately and should be addressed as are other health disparities. Future studies should identify the most promising modifiable risk factors and preventive interventions, explore the causes of death among delinquent female youth, and examine whether minority youth express suicidal intent by putting themselves at risk for homicide.

Victim of a dictatorial regime: Identification of Mr. Roberto Gomensoro Josman

Forensic cases are ideal to test osteological techniques developed by physical anthropologists. Forensic anthropology is a scientific discipline that applies population-based standards to individual skeletal remains. Many complex techniques are used in an attempt to make a positive identification. Several of these techniques, specifically digital video superimposition and DNA, were used to identify the victim in this case. The purpose of this paper is to describe anthropological techniques used to identify the remains of an unknown person who was later identified as Mr. Roberto Gomensoro Josman, the victim of a Uruguayan dictatorial regime. Mr. Gomensoro Josman disappeared after authorities of the Uruguayan dictatorial government (1973–1984) arrested him. Six days later an unknown body was found floating in Lake Rincón del Bonete. The corpse was found tied with wire and weighted with three large stones used to keep the body submerged. An autopsy was performed and the body was buried as an unknown person in the grave identified as number 10936 of Tacuarembó Cemetery. On December 2002 the Peace and Justice Service asked the local judge to authorize the exhumation of the remains. The exhumed body was headless. An investigation revealed that the local medical examiner who had autopsied the remains on March 1973 had retained the victim's skull in his office. Osteological analysis indicated the victim was a white male in his 20s. Four good quality photographs of Mr. Gomensoro who was known to be missing were compared with the skull. To confirm the identification from the video a DNA analysis was carried out comparing the victim with relatives. DNA typing confirmed the results of the earlier identification.

Who to report to the coroner? A survey of intensive care unit directors and Her Majesty's Coroners in England and Wales.

We performed a postal survey to assess the ability of intensive care unit directors and Her Majesty's Coroners to recognise deaths that should be reported to the local coroner. The survey questionnaire consisted of 12 hypothetical case scenarios. Coroners were significantly better at identifying reportable deaths than intensive care unit directors (median correct recognition scores of 11 (interquartile range 9.25-11) vs. 8 (interquartile range 7-10), respectively, p < 0.01). Deaths associated with an accident, medical treatments, industrial disease, neglect and substance abuse were significantly under-reported by intensive care unit directors (p < 0.01). Results show that significant numbers of deaths on intensive care units in England and Wales may not be being referred for further investigation, and that wide variation in local coroners' practices exists. Improvements in postgraduate medicolegal education about deaths reportable to a coroner are required. National regulations need to be more detailed and standardised so that regional variation is eliminated.

Motorcycle casualties sustained during daytona beach bike week 2000: lessons learned

Study objective: In March 2000, an estimated 500,000 people attended an annual motorcycle rally in Daytona Beach, FL, where approximately 64,000 residents live year-round. The media reported 15 deaths during this 10-day event. To more comprehensively assess the extent of trauma and need for emergency medical care, we investigated all motorcycle crashes, regardless of outcome. Methods: Motorcycle-related crash data from local medical examiner, hospital, emergency medical services (EMS), and police sources were linked. Frequencies of crashes, injuries, hospitalizations, and deaths were determined, and EMS use data were analyzed. Results: During Bike Week 2000, 570 people were involved in 281 motorcycle-related crashes. Two hundred thirty (40%) people were injured, of which 147 (64%) sought treatment in emergency departments, 72 (31%) were hospitalized, and 11 (5%) died. In crashes between motorcycles and passenger cars, individuals exposed as motorcycle occupants were 8.7 times more likely to be injured than car occupants (95% confidence limit 1.7, 15.7). Of 205 EMS dispatches for motorcycle-related crashes, two thirds resulted in transport to an ED. Data needed to assess known risk factors (eg, alcohol use, speed, lack of helmet use) were not routinely ascertained at either the crash site or ED. Conclusion: Although fatalities first called attention to the problem, nonfatal injuries outnumbered deaths 20:1. The manpower resources of civil service and health resources could become overwhelmed or exhausted in circumstances in which many people are injured or killed throughout a relatively long period. The situation deserves future study. Better risk factor surveillance is needed to help prevent crashes. [Ann Emerg Med. 2003;41:792-797.]