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Commentary: Pedestrian Fatalities—A Problem on the Rise

2013; Elsevier BV; Volume: 62; Issue: 6 Linguagem: Inglês

10.1016/j.annemergmed.2013.09.019

1097-6760

Gregory C. Patek, Todd Thoma,

Trauma and Emergency Care Studies

[Patek GC, Thoma TG. Commentary: pedestrian fatalities—a problem on the rise. Ann Emerg Med. 2013;62:613–615.]It’s the call everyone knows will come one day but secretly hopes it comes on someone else’s shift. The ambulance crew calls with a patient report. They are running a trauma code on a male child, perhaps 5 or 6 years old, who was hit by a car while in the street. Incoherent details come across the line. The medics quickly get off the telephone to resume their duties. Estimated time of arrival is 5 minutes. The next 30 minutes are a blur. We all know that no effort is spared to resuscitate children, especially the ones who only minutes earlier were full of life and promise. Unfortunately, these efforts often result only in the knowledge that everyone did everything in their power to save a life cut short by senseless tragedy. All that remains are hollow words no parent wants to hear.Significant reductions in fatality rates among several categories of road users have been realized in recent years. Advancements in automotive engineering, mandatory seat belt use requirements, and positive behavioral changes have made road use safer year after year. These advancements are indirectly evidenced in the decline of total fatality rate on our nation’s roadways in recent years. One notable exception to this decline has been the rate of pedestrian fatalities, which has increased recently. From 2002 until 2009, the total number of pedestrian deaths declined every year except 1 (2004 to 2005). However, for the last 2 years, from 2009 to 2011, total pedestrian deaths (in absolute numbers) increased 4.7% and 3.0%, respectively.1National Highway Traffic Safety AdministrationTraffic Safety Facts 2011 Data—Pedestrians. National Highway Traffic Safety Administration, Washington, DC2013http://www-nrd.nhtsa.dot.gov/Pubs/811748.pdfGoogle Scholar In contrast, overall highway fatalities declined 1.9% from 2010 to 2011 and a substantial 26% between 2005 and 2011.2National Highway Traffic Safety Administration. New NHTSA analysis shows 2011 traffic fatalities declined by nearly two percent. NHTSA 47–12. December 10, 2012. Available at: http://www.nhtsa.gov/About+NHTSA/Press+Releases/New+NHTSA+Analysis+Shows+2011+Traffic+Fatalities+Declined+by+Nearly+Two+Percent. Accessed August 17, 2013.Google Scholar Historically, pedestrian fatalities represent approximately 11% to 12% of all fatalities on our nation’s roadways. However, in 2010 and 2011 pedestrian fatalities represented 13% and 14% of all roadway fatalities, respectively.1National Highway Traffic Safety AdministrationTraffic Safety Facts 2011 Data—Pedestrians. National Highway Traffic Safety Administration, Washington, DC2013http://www-nrd.nhtsa.dot.gov/Pubs/811748.pdfGoogle Scholar After nearly 7 years of pedestrian fatality reductions, there has been an unexplained and perhaps inexplicable increase in pedestrian death rates.Many factors play a role in pedestrian fatalities. Several of the most significant factors include substantial alcohol use by drivers and pedestrians alike, the time of day of the incident, pedestrian age, and sex.1National Highway Traffic Safety AdministrationTraffic Safety Facts 2011 Data—Pedestrians. National Highway Traffic Safety Administration, Washington, DC2013http://www-nrd.nhtsa.dot.gov/Pubs/811748.pdfGoogle Scholar Perhaps, and probably likely, time of day and alcohol use are not independent and often play an interactive role because most people who drive or walk intoxicated are more likely to do so at certain times of day and on particular days of the week.3Voas RB, Fell JC. Preventing alcohol-related problems through health policy research. Available at: http://pubs.niaaa.nih.gov/publications/arh40/18-28.htm. Accessed August 18, 2013.Google Scholar Additional important factors that are also probably related are age and male sex. Being young and of male sex is associated with risk-taking behaviors that can result in bad outcomes. Factor alcohol into this equation and the results can be catastrophic. Pedestrian fatalities are no exception to this well-established rule, as we will see below.In 2011, 71% of all pedestrian fatalities occurred between 4 pm and 4 am. Thirty-two percent of fatalities occurred between 8 pm and midnight. Although alcohol plays a role in nearly half of these deaths, the other half are related to sundry factors. Diminished capability of the human visual system under mesopic (twilight or dusk) or scotopic (nighttime) conditions is one reason for the increase in deaths during evening hours. Driving at daytime highway speeds during twilight or evening hours can result in overdriving your car’s headlights (when you go so fast that your stopping distance is farther than you can see with your headlights).5Ministry of Transportation. Driving at night and in bad weather. Available at: http://www.mto.gov.on.ca/english/dandv/driver/handbook/section2.11.1.shtml. Accessed August 18, 2013.Google Scholar Normal reaction time may not be enough when a pedestrian appears in view of an automobile’s headlights. This is of particular significance when pedestrians are walking on roadways where the driver does not expect them. An example of this is a closed-access highway where vehicles are also traveling at high rates of speed.4National Highway Traffic Safety Administration. Safety 1n num3ers. Available at: http://www.nhtsa.gov/nhtsa/Safety1nNum3ers/august2013/SafetyInNumbersAugust2013.html. Accessed August 18, 2013.Google Scholar Walking at night predisposes pedestrians to increased risk of death and injury. Adding other factors such as alcohol, young or inexperienced drivers, and vehicle speeds too fast for the circumstances makes for a dangerous and often lethal cocktail for pedestrians.Alcohol use by either the driver or the pedestrian plays a role in 48% of all pedestrian fatalities.4National Highway Traffic Safety Administration. Safety 1n num3ers. Available at: http://www.nhtsa.gov/nhtsa/Safety1nNum3ers/august2013/SafetyInNumbersAugust2013.html. Accessed August 18, 2013.Google Scholar Alcohol use by the pedestrian plays a much higher role in pedestrian fatalities than does alcohol use by the involved driver. Sixteen percent of drivers involved in pedestrian fatalities had detectable levels of alcohol in their blood. Eighty-one percent of these drivers had a BAC of 0.08 g/dL or greater, which translates into 13% of the drivers involved in pedestrian fatalities being over the legal BAC limit to operate a motor vehicle.1National Highway Traffic Safety AdministrationTraffic Safety Facts 2011 Data—Pedestrians. National Highway Traffic Safety Administration, Washington, DC2013http://www-nrd.nhtsa.dot.gov/Pubs/811748.pdfGoogle Scholar Contrast this with the fact that 37% of pedestrians killed have a BAC of at least 0.08 g/dL. Approximately half of all pedestrians aged between 21 and 54 years who are killed in motor vehicle crashes have a BAC of 0.08 g/dL at their deaths. It is clear that alcohol use, particularly among pedestrians, plays a substantial role in pedestrian fatalities. Not surprisingly, many pedestrian fatalities (39%) occur on weekend evenings between 8 pm and midnight.1National Highway Traffic Safety AdministrationTraffic Safety Facts 2011 Data—Pedestrians. National Highway Traffic Safety Administration, Washington, DC2013http://www-nrd.nhtsa.dot.gov/Pubs/811748.pdfGoogle Scholar Alcohol use among individuals out on the weekend evenings is presumably higher than at any other time of day or day of the week. It is well established that alcohol use impairs judgment, predisposes to risk-taking behavior, slows reaction time, impairs coordination, and impairs visual capabilities.6National Institute on Alcohol Abuse and Alcoholism. Beyond hangovers: understanding alcohol’s impact on your health. Available at: http://pubs.niaaa.nih.gov/publications/Hangovers/beyondHangovers.pdf. Accessed August 18, 2013.Google Scholar, 7Morante P. Mesopic street lighting demonstration and evaluation final report. Available at: http://www.lrc.rpi.edu/researchareas/pdf/grotonfinalreport.pdf. Accessed August 18, 2013.Google Scholar Some of these, in one manner or another, likely factor into alcohol-related pedestrian fatalities.As previously mentioned, male sex is associated with higher rates of pedestrian fatality. In 2011, 70% of pedestrian fatalities were male victims. The male pedestrian fatality rate per 100,000 population was 2.01—more than double the rate for female pedestrians (0.85 per 100,000 population).1National Highway Traffic Safety AdministrationTraffic Safety Facts 2011 Data—Pedestrians. National Highway Traffic Safety Administration, Washington, DC2013http://www-nrd.nhtsa.dot.gov/Pubs/811748.pdfGoogle Scholar The pedestrian injury rate for male pedestrians is 24 per 100,000 population compared with 20 per 100,000 for female pedestrians. Male and female pedestrians are injured in pedestrian crashes at a fairly similar rate, but men are much more likely to die when involved in a pedestrian crash.1National Highway Traffic Safety AdministrationTraffic Safety Facts 2011 Data—Pedestrians. National Highway Traffic Safety Administration, Washington, DC2013http://www-nrd.nhtsa.dot.gov/Pubs/811748.pdfGoogle ScholarMany municipalities have taken steps to combat this issue. Federal funding has targeted research to high-risk locales, supporting the implementation of safety measures that apply directly and solely to pedestrian safety. Some measures apply to all forms of highway safety, not just pedestrians. For example, some states have specific nighttime speed limits to help increase safety during more dangerous evening hours. Other programs support enforcement of laws prohibiting driving while alcohol impaired. Enforcement of these laws makes roadways safer for everyone by reducing the number of drivers who exhibit this risky behavior. Projects to improve lighting of roadways with high rates of pedestrian traffic (and roadways identified to be high risk for pedestrians) should also be undertaken to make pedestrians more visible to drivers during evening hours. These, among other legal and infrastructural interventions, are at the root of improved pedestrian safety.The following are recommendations and important safety reminders from the National Highway Traffic Safety Administration’s Safety Countermeasures Division1National Highway Traffic Safety AdministrationTraffic Safety Facts 2011 Data—Pedestrians. National Highway Traffic Safety Administration, Washington, DC2013http://www-nrd.nhtsa.dot.gov/Pubs/811748.pdfGoogle Scholar:For PedestriansWalk on a sidewalk or path whenever one is available.If there is no sidewalk or path available, walk facing traffic (on the left side of the road) on the shoulder, as far away from traffic as possible. Keep alert at all times; do not be distracted by electronic devices, including radios, smartphones, and other devices that take your eyes (and ears) off the road environment.Be cautious night and day when sharing the road with vehicles. Never assume a driver sees you (he or she could be distracted, could be under the influence of alcohol or drugs, or could simply not see you). Try to make eye contact with drivers as they approach you to make sure you are seen.Be predictable as a pedestrian. Cross streets at crosswalks or intersections whenever possible. This is where drivers expect pedestrians.If a crosswalk or intersection is not available, locate a well-lit area, wait for a gap in traffic that allows you enough time to cross safely, and continue to watch for traffic as you cross.Stay off of freeways, restricted-access highways, and other pedestrian-prohibited roadways.Be visible at all times. Wear bright clothing during the day, and wear reflective materials or use a flashlight at night.Avoid alcohol and drugs when walking; they impair your abilities and judgment too.For DriversLook out for pedestrians everywhere at all times. Often pedestrians are not walking where they should be.Be especially vigilant for pedestrians in hard-to-see conditions, such as nighttime or in bad weather.Slow down and be prepared to stop when turning or otherwise entering a crosswalk.Always stop for pedestrians in crosswalks and stop well back from the crosswalk to give other vehicles an opportunity to see the crossing pedestrians so they can stop too.Never pass vehicles stopped at a crosswalk. They are stopped to allow pedestrians to cross the street.Never drive under the influence of alcohol or drugs.Follow the speed limit, especially around pedestrians.Follow slower speed limits in school zones and in neighborhoods where there are children present.Certainly many of the important issues relating to this significant problem are the purview of government officials, law enforcement, civil engineers, and scientists. Their inventions and interventions will make our roadways safer as time goes on. The question then remains, what can we do as emergency physicians as it relates to this important public safety issue? Perhaps the best answer lies in a policy introduced by the American College of Emergency Physicians (ACEP). This policy relates to emergency department (ED) or trauma center interventions proven to help decrease the recurrence of alcohol-related injuries when applied to patients with alcohol use disorders.Research suggests that 30% to 50% of injured, crash-involved drivers admitted to EDs or trauma centers have BACs higher than the 0.08 g/dL limit for driving. Many of these drivers are never charged, however, because they are taken to the hospital before a police officer has an opportunity to examine them for impairment, and hospital staff rarely notify the police when they receive a high-BAC driver. An estimated 27% of injured patients admitted to EDs or trauma centers test positive for alcohol abuse or dependence. This suggests a large reservoir of people impaired by alcohol who are potential driving-while-intoxicated offenders.These situations represent significant lost opportunities to intervene with high-risk drinkers who need treatment for alcohol problems. Screening and brief interventions have been found effective among people who have not directly sought treatment, such as ED patients.Brief interventions are time-limited treatments that generally consist of 1 to 4 sessions ranging from 5 to 50 minutes. Typically, program leaders assess drinking levels, provide normative feedback, address and enhance the client’s motivation to change, and negotiate goals about drinking rates. They frequently use motivational enhancement therapy based on the transtheoretical stages of change theory, provide a menu of change options, are empathetic, and are nonconfrontational. Although brief interventions can be successful, both in the short and in the long term, effects on alcohol consumption seem to diminish over time, whereas effects on reducing alcohol-related injuries, crashes, and driving violations appear to continue during longer periods. This may indicate that many recipients of brief intervention use strategies to avoid being injured while they are drinking, such as using a designated driver or not participating in high-risk activities.EDs and trauma centers using screening and brief interventions benefit from patients having fewer subsequent ED visits, fewer days in the hospital, and fewer new injuries. Most important, however, is that people who receive the brief interventions reduce their driving-related problems, such as traffic violations, other arrests, or general legal involvements; drinking-and-driving violations; and injuries and fatalities from motor vehicle crashes.In the fall of 2006, ACEP began to suggest that all Level I trauma centers have a procedure to screen and provide brief interventions to problem drinkers. Despite the lack of mandatory requirements in the past, screening and brief interventions for alcohol use disorders are becoming the standard of care in trauma centers because of their proven effectiveness in reducing hazardous and harmful drinking practices, particularly as they relate to motor vehicle injuries.3Voas RB, Fell JC. Preventing alcohol-related problems through health policy research. Available at: http://pubs.niaaa.nih.gov/publications/arh40/18-28.htm. Accessed August 18, 2013.Google ScholarBecause nearly half of all pedestrian fatalities are alcohol related, perhaps our brief intervention at these particularly vulnerable times can serve to decrease future rates of alcohol-related injuries in general and alcohol-related pedestrian injuries and fatalities in particular. [Patek GC, Thoma TG. Commentary: pedestrian fatalities—a problem on the rise. Ann Emerg Med. 2013;62:613–615.] It’s the call everyone knows will come one day but secretly hopes it comes on someone else’s shift. The ambulance crew calls with a patient report. They are running a trauma code on a male child, perhaps 5 or 6 years old, who was hit by a car while in the street. Incoherent details come across the line. The medics quickly get off the telephone to resume their duties. Estimated time of arrival is 5 minutes. The next 30 minutes are a blur. We all know that no effort is spared to resuscitate children, especially the ones who only minutes earlier were full of life and promise. Unfortunately, these efforts often result only in the knowledge that everyone did everything in their power to save a life cut short by senseless tragedy. All that remains are hollow words no parent wants to hear. Significant reductions in fatality rates among several categories of road users have been realized in recent years. Advancements in automotive engineering, mandatory seat belt use requirements, and positive behavioral changes have made road use safer year after year. These advancements are indirectly evidenced in the decline of total fatality rate on our nation’s roadways in recent years. One notable exception to this decline has been the rate of pedestrian fatalities, which has increased recently. From 2002 until 2009, the total number of pedestrian deaths declined every year except 1 (2004 to 2005). However, for the last 2 years, from 2009 to 2011, total pedestrian deaths (in absolute numbers) increased 4.7% and 3.0%, respectively.1National Highway Traffic Safety AdministrationTraffic Safety Facts 2011 Data—Pedestrians. National Highway Traffic Safety Administration, Washington, DC2013http://www-nrd.nhtsa.dot.gov/Pubs/811748.pdfGoogle Scholar In contrast, overall highway fatalities declined 1.9% from 2010 to 2011 and a substantial 26% between 2005 and 2011.2National Highway Traffic Safety Administration. New NHTSA analysis shows 2011 traffic fatalities declined by nearly two percent. NHTSA 47–12. December 10, 2012. Available at: http://www.nhtsa.gov/About+NHTSA/Press+Releases/New+NHTSA+Analysis+Shows+2011+Traffic+Fatalities+Declined+by+Nearly+Two+Percent. Accessed August 17, 2013.Google Scholar Historically, pedestrian fatalities represent approximately 11% to 12% of all fatalities on our nation’s roadways. However, in 2010 and 2011 pedestrian fatalities represented 13% and 14% of all roadway fatalities, respectively.1National Highway Traffic Safety AdministrationTraffic Safety Facts 2011 Data—Pedestrians. National Highway Traffic Safety Administration, Washington, DC2013http://www-nrd.nhtsa.dot.gov/Pubs/811748.pdfGoogle Scholar After nearly 7 years of pedestrian fatality reductions, there has been an unexplained and perhaps inexplicable increase in pedestrian death rates. Many factors play a role in pedestrian fatalities. Several of the most significant factors include substantial alcohol use by drivers and pedestrians alike, the time of day of the incident, pedestrian age, and sex.1National Highway Traffic Safety AdministrationTraffic Safety Facts 2011 Data—Pedestrians. National Highway Traffic Safety Administration, Washington, DC2013http://www-nrd.nhtsa.dot.gov/Pubs/811748.pdfGoogle Scholar Perhaps, and probably likely, time of day and alcohol use are not independent and often play an interactive role because most people who drive or walk intoxicated are more likely to do so at certain times of day and on particular days of the week.3Voas RB, Fell JC. Preventing alcohol-related problems through health policy research. Available at: http://pubs.niaaa.nih.gov/publications/arh40/18-28.htm. Accessed August 18, 2013.Google Scholar Additional important factors that are also probably related are age and male sex. Being young and of male sex is associated with risk-taking behaviors that can result in bad outcomes. Factor alcohol into this equation and the results can be catastrophic. Pedestrian fatalities are no exception to this well-established rule, as we will see below. In 2011, 71% of all pedestrian fatalities occurred between 4 pm and 4 am. Thirty-two percent of fatalities occurred between 8 pm and midnight. Although alcohol plays a role in nearly half of these deaths, the other half are related to sundry factors. Diminished capability of the human visual system under mesopic (twilight or dusk) or scotopic (nighttime) conditions is one reason for the increase in deaths during evening hours. Driving at daytime highway speeds during twilight or evening hours can result in overdriving your car’s headlights (when you go so fast that your stopping distance is farther than you can see with your headlights).5Ministry of Transportation. Driving at night and in bad weather. Available at: http://www.mto.gov.on.ca/english/dandv/driver/handbook/section2.11.1.shtml. Accessed August 18, 2013.Google Scholar Normal reaction time may not be enough when a pedestrian appears in view of an automobile’s headlights. This is of particular significance when pedestrians are walking on roadways where the driver does not expect them. An example of this is a closed-access highway where vehicles are also traveling at high rates of speed.4National Highway Traffic Safety Administration. Safety 1n num3ers. Available at: http://www.nhtsa.gov/nhtsa/Safety1nNum3ers/august2013/SafetyInNumbersAugust2013.html. Accessed August 18, 2013.Google Scholar Walking at night predisposes pedestrians to increased risk of death and injury. Adding other factors such as alcohol, young or inexperienced drivers, and vehicle speeds too fast for the circumstances makes for a dangerous and often lethal cocktail for pedestrians. Alcohol use by either the driver or the pedestrian plays a role in 48% of all pedestrian fatalities.4National Highway Traffic Safety Administration. Safety 1n num3ers. Available at: http://www.nhtsa.gov/nhtsa/Safety1nNum3ers/august2013/SafetyInNumbersAugust2013.html. Accessed August 18, 2013.Google Scholar Alcohol use by the pedestrian plays a much higher role in pedestrian fatalities than does alcohol use by the involved driver. Sixteen percent of drivers involved in pedestrian fatalities had detectable levels of alcohol in their blood. Eighty-one percent of these drivers had a BAC of 0.08 g/dL or greater, which translates into 13% of the drivers involved in pedestrian fatalities being over the legal BAC limit to operate a motor vehicle.1National Highway Traffic Safety AdministrationTraffic Safety Facts 2011 Data—Pedestrians. National Highway Traffic Safety Administration, Washington, DC2013http://www-nrd.nhtsa.dot.gov/Pubs/811748.pdfGoogle Scholar Contrast this with the fact that 37% of pedestrians killed have a BAC of at least 0.08 g/dL. Approximately half of all pedestrians aged between 21 and 54 years who are killed in motor vehicle crashes have a BAC of 0.08 g/dL at their deaths. It is clear that alcohol use, particularly among pedestrians, plays a substantial role in pedestrian fatalities. Not surprisingly, many pedestrian fatalities (39%) occur on weekend evenings between 8 pm and midnight.1National Highway Traffic Safety AdministrationTraffic Safety Facts 2011 Data—Pedestrians. National Highway Traffic Safety Administration, Washington, DC2013http://www-nrd.nhtsa.dot.gov/Pubs/811748.pdfGoogle Scholar Alcohol use among individuals out on the weekend evenings is presumably higher than at any other time of day or day of the week. It is well established that alcohol use impairs judgment, predisposes to risk-taking behavior, slows reaction time, impairs coordination, and impairs visual capabilities.6National Institute on Alcohol Abuse and Alcoholism. Beyond hangovers: understanding alcohol’s impact on your health. Available at: http://pubs.niaaa.nih.gov/publications/Hangovers/beyondHangovers.pdf. Accessed August 18, 2013.Google Scholar, 7Morante P. Mesopic street lighting demonstration and evaluation final report. Available at: http://www.lrc.rpi.edu/researchareas/pdf/grotonfinalreport.pdf. Accessed August 18, 2013.Google Scholar Some of these, in one manner or another, likely factor into alcohol-related pedestrian fatalities. As previously mentioned, male sex is associated with higher rates of pedestrian fatality. In 2011, 70% of pedestrian fatalities were male victims. The male pedestrian fatality rate per 100,000 population was 2.01—more than double the rate for female pedestrians (0.85 per 100,000 population).1National Highway Traffic Safety AdministrationTraffic Safety Facts 2011 Data—Pedestrians. National Highway Traffic Safety Administration, Washington, DC2013http://www-nrd.nhtsa.dot.gov/Pubs/811748.pdfGoogle Scholar The pedestrian injury rate for male pedestrians is 24 per 100,000 population compared with 20 per 100,000 for female pedestrians. Male and female pedestrians are injured in pedestrian crashes at a fairly similar rate, but men are much more likely to die when involved in a pedestrian crash.1National Highway Traffic Safety AdministrationTraffic Safety Facts 2011 Data—Pedestrians. National Highway Traffic Safety Administration, Washington, DC2013http://www-nrd.nhtsa.dot.gov/Pubs/811748.pdfGoogle Scholar Many municipalities have taken steps to combat this issue. Federal funding has targeted research to high-risk locales, supporting the implementation of safety measures that apply directly and solely to pedestrian safety. Some measures apply to all forms of highway safety, not just pedestrians. For example, some states have specific nighttime speed limits to help increase safety during more dangerous evening hours. Other programs support enforcement of laws prohibiting driving while alcohol impaired. Enforcement of these laws makes roadways safer for everyone by reducing the number of drivers who exhibit this risky behavior. Projects to improve lighting of roadways with high rates of pedestrian traffic (and roadways identified to be high risk for pedestrians) should also be undertaken to make pedestrians more visible to drivers during evening hours. These, among other legal and infrastructural interventions, are at the root of improved pedestrian safety. The following are recommendations and important safety reminders from the National Highway Traffic Safety Administration’s Safety Countermeasures Division1National Highway Traffic Safety AdministrationTraffic Safety Facts 2011 Data—Pedestrians. National Highway Traffic Safety Administration, Washington, DC2013http://www-nrd.nhtsa.dot.gov/Pubs/811748.pdfGoogle Scholar: For PedestriansWalk on a sidewalk or path whenever one is available.If there is no sidewalk or path available, walk facing traffic (on the left side of the road) on the shoulder, as far away from traffic as possible. Keep alert at all times; do not be distracted by electronic devices, including radios, smartphones, and other devices that take your eyes (and ears) off the road environment.Be cautious night and day when sharing the road with vehicles. Never assume a driver sees you (he or she could be distracted, could be under the influence of alcohol or drugs, or could simply not see you). Try to make eye contact with drivers as they approach you to make sure you are seen.Be predictable as a pedestrian. Cross streets at crosswalks or intersections whenever possible. This is where drivers expect pedestrians.If a crosswalk or intersection is not available, locate a well-lit area, wait for a gap in traffic that allows you enough time to cross safely, and continue to watch for traffic as you cross.Stay off of freeways, restricted-access highways, and other pedestrian-prohibited roadways.Be visible at all times. Wear bright clothing during the day, and wear reflective materials or use a flashlight at night.Avoid alcohol and drugs when walking; they impair your abilities and judgment too. Walk on a sidewalk or path whenever one is available. If there is no sidewalk or path available, walk facing traffic (on the left side of the road) on the shoulder, as far away from traffic as possible. Keep alert at all times; do not be distracted by electronic devices, including radios, smartphones, and other devices that take your eyes (and ears) off the road environment. Be cautious night and day when sharing the road with vehicles. Never assume a driver sees you (he or she could be distracted, could be under the influence of alcohol or drugs, or could simply not see you). Try to make eye contact with drivers as they approach you to make sure you are seen. Be predictable as a pedestrian. Cross streets at crosswalks or intersections whenever possible. This is where drivers expect pedestrians. If a crosswalk or intersection is not available, locate a well-lit area, wait for a gap in traffic that allows you enough time to cross safely, and continue to watch for traffic as you cross. Stay off of freeways, restricted-access highways, and other pedestrian-prohibited roadways. Be visible at all times. Wear bright clothing during the day, and wear reflective materials or use a flashlight at night. Avoid alcohol and drugs when walking; they impair your abilities and judgment too. For DriversLook out for pedestrians everywhere at all times. Often pedestrians are not walking where they should be.Be especially vigilant for pedestrians in hard-to-see conditions, such as nighttime or in bad weather.Slow down and be prepared to stop when turning or otherwise entering a crosswalk.Always stop for pedestrians in crosswalks and stop well back from the crosswalk to give other vehicles an opportunity to see the crossing pedestrians so they can stop too.Never pass vehicles stopped at a crosswalk. They are stopped to allow pedestrians to cross the street.Never drive under the influence of alcohol or drugs.Follow the speed limit, especially around pedestrians.Follow slower speed limits in school zones and in neighborhoods where there are children present.Certainly many of the important issues relating to this significant problem are the purview of government officials, law enforcement, civil engineers, and scientists. Their inventions and interventions will make our roadways safer as time goes on. The question then remains, what can we do as emergency physicians as it relates to this important public safety issue? Perhaps the best answer lies in a policy introduced by the American College of Emergency Physicians (ACEP). This policy relates to emergency department (ED) or trauma center interventions proven to help decrease the recurrence of alcohol-related injuries when applied to patients with alcohol use disorders.Research suggests that 30% to 50% of injured, crash-involved drivers admitted to EDs or trauma centers have BACs higher than the 0.08 g/dL limit for driving. Many of these drivers are never charged, however, because they are taken to the hospital before a police officer has an opportunity to examine them for impairment, and hospital staff rarely notify the police when they receive a high-BAC driver. An estimated 27% of injured patients admitted to EDs or trauma centers test positive for alcohol abuse or dependence. This suggests a large reservoir of people impaired by alcohol who are potential driving-while-intoxicated offenders.These situations represent significant lost opportunities to intervene with high-risk drinkers who need treatment for alcohol problems. Screening and brief interventions have been found effective among people who have not directly sought treatment, such as ED patients.Brief interventions are time-limited treatments that generally consist of 1 to 4 sessions ranging from 5 to 50 minutes. Typically, program leaders assess drinking levels, provide normative feedback, address and enhance the client’s motivation to change, and negotiate goals about drinking rates. They frequently use motivational enhancement therapy based on the transtheoretical stages of change theory, provide a menu of change options, are empathetic, and are nonconfrontational. Although brief interventions can be successful, both in the short and in the long term, effects on alcohol consumption seem to diminish over time, whereas effects on reducing alcohol-related injuries, crashes, and driving violations appear to continue during longer periods. This may indicate that many recipients of brief intervention use strategies to avoid being injured while they are drinking, such as using a designated driver or not participating in high-risk activities.EDs and trauma centers using screening and brief interventions benefit from patients having fewer subsequent ED visits, fewer days in the hospital, and fewer new injuries. Most important, however, is that people who receive the brief interventions reduce their driving-related problems, such as traffic violations, other arrests, or general legal involvements; drinking-and-driving violations; and injuries and fatalities from motor vehicle crashes.In the fall of 2006, ACEP began to suggest that all Level I trauma centers have a procedure to screen and provide brief interventions to problem drinkers. Despite the lack of mandatory requirements in the past, screening and brief interventions for alcohol use disorders are becoming the standard of care in trauma centers because of their proven effectiveness in reducing hazardous and harmful drinking practices, particularly as they relate to motor vehicle injuries.3Voas RB, Fell JC. Preventing alcohol-related problems through health policy research. Available at: http://pubs.niaaa.nih.gov/publications/arh40/18-28.htm. Accessed August 18, 2013.Google ScholarBecause nearly half of all pedestrian fatalities are alcohol related, perhaps our brief intervention at these particularly vulnerable times can serve to decrease future rates of alcohol-related injuries in general and alcohol-related pedestrian injuries and fatalities in particular. Look out for pedestrians everywhere at all times. Often pedestrians are not walking where they should be. Be especially vigilant for pedestrians in hard-to-see conditions, such as nighttime or in bad weather. Slow down and be prepared to stop when turning or otherwise entering a crosswalk. Always stop for pedestrians in crosswalks and stop well back from the crosswalk to give other vehicles an opportunity to see the crossing pedestrians so they can stop too. Never pass vehicles stopped at a crosswalk. They are stopped to allow pedestrians to cross the street. Never drive under the influence of alcohol or drugs. Follow the speed limit, especially around pedestrians. Follow slower speed limits in school zones and in neighborhoods where there are children present. Certainly many of the important issues relating to this significant problem are the purview of government officials, law enforcement, civil engineers, and scientists. Their inventions and interventions will make our roadways safer as time goes on. The question then remains, what can we do as emergency physicians as it relates to this important public safety issue? Perhaps the best answer lies in a policy introduced by the American College of Emergency Physicians (ACEP). This policy relates to emergency department (ED) or trauma center interventions proven to help decrease the recurrence of alcohol-related injuries when applied to patients with alcohol use disorders. Research suggests that 30% to 50% of injured, crash-involved drivers admitted to EDs or trauma centers have BACs higher than the 0.08 g/dL limit for driving. Many of these drivers are never charged, however, because they are taken to the hospital before a police officer has an opportunity to examine them for impairment, and hospital staff rarely notify the police when they receive a high-BAC driver. An estimated 27% of injured patients admitted to EDs or trauma centers test positive for alcohol abuse or dependence. This suggests a large reservoir of people impaired by alcohol who are potential driving-while-intoxicated offenders. These situations represent significant lost opportunities to intervene with high-risk drinkers who need treatment for alcohol problems. Screening and brief interventions have been found effective among people who have not directly sought treatment, such as ED patients. Brief interventions are time-limited treatments that generally consist of 1 to 4 sessions ranging from 5 to 50 minutes. Typically, program leaders assess drinking levels, provide normative feedback, address and enhance the client’s motivation to change, and negotiate goals about drinking rates. They frequently use motivational enhancement therapy based on the transtheoretical stages of change theory, provide a menu of change options, are empathetic, and are nonconfrontational. Although brief interventions can be successful, both in the short and in the long term, effects on alcohol consumption seem to diminish over time, whereas effects on reducing alcohol-related injuries, crashes, and driving violations appear to continue during longer periods. This may indicate that many recipients of brief intervention use strategies to avoid being injured while they are drinking, such as using a designated driver or not participating in high-risk activities. EDs and trauma centers using screening and brief interventions benefit from patients having fewer subsequent ED visits, fewer days in the hospital, and fewer new injuries. Most important, however, is that people who receive the brief interventions reduce their driving-related problems, such as traffic violations, other arrests, or general legal involvements; drinking-and-driving violations; and injuries and fatalities from motor vehicle crashes. In the fall of 2006, ACEP began to suggest that all Level I trauma centers have a procedure to screen and provide brief interventions to problem drinkers. Despite the lack of mandatory requirements in the past, screening and brief interventions for alcohol use disorders are becoming the standard of care in trauma centers because of their proven effectiveness in reducing hazardous and harmful drinking practices, particularly as they relate to motor vehicle injuries.3Voas RB, Fell JC. Preventing alcohol-related problems through health policy research. Available at: http://pubs.niaaa.nih.gov/publications/arh40/18-28.htm. Accessed August 18, 2013.Google Scholar Because nearly half of all pedestrian fatalities are alcohol related, perhaps our brief intervention at these particularly vulnerable times can serve to decrease future rates of alcohol-related injuries in general and alcohol-related pedestrian injuries and fatalities in particular.